NPIMap

Organization Active NPI

Crisp Regional Hospital, Inc

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Cordele, GA
National Provider Identifier
1457329377
Registry record updated Jun 12, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
End-Stage Renal Disease (ESRD) Treatment Clinic/CenterTaxonomy code 261QE0700X
License
ESRD001001 Issued in GA
Legal business name
CRISP REGIONAL HOSPITAL, INC
Practice address
902 N 7TH St
Cordele, GA 31015-3234
Phone
(229) 276-3100
Fax
(229) 276-3297
NPI assigned
Mar 8, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 12, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Susan Wade Wilder
Title
Internal Auditor
Phone
(229) 276-3100

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
End-Stage Renal Disease (ESRD) Treatment Clinic/Center 261QE0700X ESRD001001 GA Primary

Addresses

Primary practice location

902 N 7TH St
Cordele, GA 31015-3234

Mailing address

902 N 7TH St
Cordele, GA 31015-3234
Phone (229) 271-9686

Other identifiers 1

IdentifierTypeStateIssuer
000431351AMedicaidGA

Other names 1

  • Crisp Regional Dialysis Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20090610000062 GA Part A Provider - End-Stage Renal Disease Facility (ESRD) 5991616336 Practice locations: Cordele, GA

Other NPIs with the same Medicare PAC ID 8

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Surgical Associates22 organizations share this tax ID, including this one

Other organizations with this tax ID 21

Organizations that report the same tax identification number in the National Provider Directory.

View all 21

Ownership & related parties

All facility ownership & control disclosures 4

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Crisp Regional HospitalCordele, GA, CCN 110104 Hospital Operational/Managerial Control (100%) Feb 1, 1996
Crisp Regional HospitalCordele, GA, CCN 11U104 Hospital Operational/Managerial Control (100%) Feb 1, 1996
Caresouth an Affiliate of Crisp Regional HospitalCordele, GA, CCN 117309 Home health agency 5% Or Greater Direct Ownership Interest Dec 14, 2007
Crisp Regional Convenient CareCordele, GA, CCN 118555 Rural health clinic Operational/Managerial Control May 1, 2012

Owned or controlled facilities with NPI records 3

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 65

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 65

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1141776000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1244764800000",
    "number": "1457329377",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "902 N 7TH ST",
            "city": "CORDELE",
            "state": "GA",
            "postal_code": "310153234",
            "telephone_number": "229-271-9686",
            "fax_number": "229-271-9689"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "902 N 7TH ST",
            "city": "CORDELE",
            "state": "GA",
            "postal_code": "310153234",
            "telephone_number": "229-276-3100",
            "fax_number": "229-276-3297"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CRISP REGIONAL HOSPITAL, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-03-08",
        "last_updated": "2009-06-12",
        "status": "A",
        "authorized_official_last_name": "WILDER",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_middle_name": "WADE",
        "authorized_official_title_or_position": "INTERNAL AUDITOR",
        "authorized_official_telephone_number": "229-276-3100"
    },
    "taxonomies": [
        {
            "code": "261QE0700X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, End-Stage Renal Disease (ESRD) Treatment",
            "state": "GA",
            "license": "ESRD001001",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000431351A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Crisp Regional Dialysis",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Cordele, GA

Sources for this page

Verify at the official NPI Registry.