Basic Information
| Provider Information | |||||||||
| NPI: | 1023253408 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TATTNALL HOSPITAL COMPANY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OPTIM PRIMARY CARE - COBBTOWN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 E DERENNE AVE | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314056736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126445300 | ||||||||
| FaxNumber: | 9126445260 | ||||||||
| Practice Location | |||||||||
| Address1: | 36671 HWY 23 | ||||||||
| Address2: | |||||||||
| City: | COBBTOWN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304206042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125571000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2008 | ||||||||
| LastUpdateDate: | 07/27/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GUENTHNER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY OF COMM.HOSP.HOLD.CO., LL | ||||||||
| AuthorizedOfficialTelephone: | 3126278427 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TATTNALL HOSPITAL COMPANY. LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 038774 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 925639844B | 05 | GA | MEDICAID | 118512 | 01 | MEDICARE PART A | OTHER |