Basic Information
| Provider Information | |||||||||
| NPI: | 1083915524 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SCREVEN COUNTY HOSPITAL LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OPTIM MEDICAL CENTER - SCREVEN | ||||||||
| 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: | 215 MIMS RD | ||||||||
| Address2: | |||||||||
| City: | SYLVANIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304671994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125647426 | ||||||||
| FaxNumber: | 9125640010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2010 | ||||||||
| LastUpdateDate: | 02/02/2012 | ||||||||
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| AuthorizedOfficialLastName: | KLEINPETER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9126445300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 124-164 | GA | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 000001647S | 05 | GA | MEDICAID |