Basic Information
| Provider Information | |||||||||
| NPI: | 1639562978 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TATTNALL HOSPITAL COMPANY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OPTIM MEDICAL CENTER - TATTNALL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 E DERENNE AVE | ||||||||
| Address2: | ATTN.: PROVIDER ENROLLMENT | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314056736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126445300 | ||||||||
| FaxNumber: | 9126445260 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 GLYNCO PKWY STE 30A | ||||||||
| Address2: | |||||||||
| City: | BRUNSWICK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315257930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126445300 | ||||||||
| FaxNumber: | 9126445260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2015 | ||||||||
| LastUpdateDate: | 07/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | PERRY | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9126445300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TATTNALL HOSPITAL COMPANY, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081P2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 2084P2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Pain Medicine | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208VP0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.