Basic Information
Provider Information | |||||||||
NPI: | 1053745968 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TATTNALL HOSPITAL COMPANY, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OPTIM PAIN MANAGEMENT-VIDALIA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 210 E DERENNE AVE | ||||||||
Address2: |   | ||||||||
City: | SAVANNAH | ||||||||
State: | GA | ||||||||
PostalCode: | 314056736 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9126445300 | ||||||||
FaxNumber: | 9126445260 | ||||||||
Practice Location | |||||||||
Address1: | 1702 MEADOWS LN STE A | ||||||||
Address2: |   | ||||||||
City: | VIDALIA | ||||||||
State: | GA | ||||||||
PostalCode: | 304747220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9125379421 | ||||||||
FaxNumber: | 9125380984 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/27/2013 | ||||||||
LastUpdateDate: | 07/27/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
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. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P2900X | 033669 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Pain Medicine |
No ID Information.