Provider Demographics
NPI:1831190958
Name:SOUTHERN REGIONAL HEALTH SYSTEM, INC
Entity type:Organization
Organization Name:SOUTHERN REGIONAL HEALTH SYSTEM, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VP & COO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-991-8000
Mailing Address - Street 1:11 UPPER RIVERDALE RD SW
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2615
Mailing Address - Country:US
Mailing Address - Phone:770-991-8000
Mailing Address - Fax:
Practice Address - Street 1:11 UPPER RIVERDALE RD SW
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2615
Practice Address - Country:US
Practice Address - Phone:770-991-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031-442282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00000404AMedicaid
GA110165Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
GA11S165Medicare Oscar/Certification
GA00000404AMedicaid