Provider Demographics
NPI:1699740498
Name:CRISP REGIONAL HOSPITAL, INC
Entity type:Organization
Organization Name:CRISP REGIONAL HOSPITAL, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUDITOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-276-3100
Mailing Address - Street 1:910 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-3254
Mailing Address - Country:US
Mailing Address - Phone:229-271-9686
Mailing Address - Fax:229-271-9689
Practice Address - Street 1:910 N 5TH ST
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-3254
Practice Address - Country:US
Practice Address - Phone:229-276-3100
Practice Address - Fax:229-276-3297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040063H251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000784198AMedicaid
GA000784198AMedicaid