Basic Information
| Provider Information | |||||||||
| NPI: | 1720322464 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TATTNALL HOSPITAL COMPANY, LLC | ||||||||
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| OtherOrganizationName: | OPTIM PRIMARY CARE-HAZLEHURST | ||||||||
| 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: | 38 S. TALLAHASSEE STREET | ||||||||
| Address2: | SUITE B | ||||||||
| City: | HAZLEHURST | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125519018 | ||||||||
| FaxNumber: | 9126445260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2012 | ||||||||
| LastUpdateDate: | 11/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | KLEINPETER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9126445300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TATTNALL HOSPITAL COMPANY LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.