Basic Information
Provider Information
NPI: 1144761826
EntityType: 2
ReplacementNPI:  
OrganizationName: TATTNALL HOSPITAL COMPANY, LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: OPTIM MEDICAL CENTER-TATTNALL(RICHMOND)
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 460 MALL BLVD
Address2: SUITE B
City: SAVANNAH
State: GA
PostalCode: 314064801
CountryCode: US
TelephoneNumber: 9126445300
FaxNumber: 9126443369
Practice Location
Address1: 60 EXCHANGE ST
Address2: SUITE B7
City: RICHMOND HILL
State: GA
PostalCode: 313247644
CountryCode: US
TelephoneNumber: 8008276536
FaxNumber: 9126445260
Other Information
ProviderEnumerationDate: 03/15/2017
LastUpdateDate: 03/15/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: CASTLEBERRY
AuthorizedOfficialFirstName: DAVID
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CEO
AuthorizedOfficialTelephone: 9126445300
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: TATTNALL HOSPITAL COMPANY, LLC
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207X00000X GAN193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansOrthopaedic Surgery 
2081P2900X GAY193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine

No ID Information.


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