Provider Demographics
NPI:1366587438
Name:SOUTHERN REGIONAL MEDICAL CENTER INC
Entity type:Organization
Organization Name:SOUTHERN REGIONAL MEDICAL CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:STOVALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-991-8165
Mailing Address - Street 1:11 UPPER RIVERDALE RD SW
Mailing Address - Street 2:BUILDING 25
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2615
Mailing Address - Country:US
Mailing Address - Phone:770-991-8662
Mailing Address - Fax:770-991-8663
Practice Address - Street 1:224 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4348
Practice Address - Country:US
Practice Address - Phone:770-991-8662
Practice Address - Fax:770-991-8663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00770272AMedicaid
GA117105Medicare ID - Type UnspecifiedPROVIDER NUMBER