Provider Demographics
NPI:1528619491
Name:HOSPITAL AUTHORITY OF WASHINGTON COUNTY
Entity type:Organization
Organization Name:HOSPITAL AUTHORITY OF WASHINGTON COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:TYRELL
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-289-1192
Mailing Address - Street 1:610 SPARTA RD
Mailing Address - Street 2:
Mailing Address - City:SANDERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31082-1860
Mailing Address - Country:US
Mailing Address - Phone:478-240-2000
Mailing Address - Fax:
Practice Address - Street 1:610 SPARTA RD
Practice Address - Street 2:
Practice Address - City:SANDERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31082-1860
Practice Address - Country:US
Practice Address - Phone:478-240-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOSPITAL AUTHORITY OF WASHINGTON COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-09-23
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000001218AMedicaid