Basic Information
| Provider Information | |||||||||
| NPI: | 1184955213 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TATTNALL HOSPITAL COMPANY LLC | ||||||||
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| OtherOrganizationName: | OPTIM MEDICAL CENTER-TATTNALL SLEEP LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 E DERENNE AVE | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126445300 | ||||||||
| FaxNumber: | 9126445260 | ||||||||
| Practice Location | |||||||||
| Address1: | 16915 HIGHWAY 67 SOUTH | ||||||||
| Address2: | SUITE A | ||||||||
| City: | STATESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126812500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2010 | ||||||||
| LastUpdateDate: | 01/11/2012 | ||||||||
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| AuthorizedOfficialLastName: | KLEINPETER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9126445300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | EDD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic |
No ID Information.