Provider Demographics
NPI:1528175593
Name:TY COBB HEALTHCARE SYSTEM
Entity type:Organization
Organization Name:TY COBB HEALTHCARE SYSTEM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MASSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-245-1290
Mailing Address - Street 1:PO BOX 589
Mailing Address - Street 2:
Mailing Address - City:ROYSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30662-0589
Mailing Address - Country:US
Mailing Address - Phone:706-245-1290
Mailing Address - Fax:706-245-1411
Practice Address - Street 1:545 COOK STREET
Practice Address - Street 2:
Practice Address - City:ROYSTON
Practice Address - State:GA
Practice Address - Zip Code:30662-0589
Practice Address - Country:US
Practice Address - Phone:706-245-1900
Practice Address - Fax:706-245-1918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-059-485314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00059562AMedicaid
115090Medicare ID - Type Unspecified