Provider Demographics
NPI:1902159429
Name:STATEWIDE HEALTHCARE INC
Entity Type:Organization
Organization Name:STATEWIDE HEALTHCARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:C
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-231-8958
Mailing Address - Street 1:102 OGLETHORPE PROFESSIONAL CT
Mailing Address - Street 2:4
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-3600
Mailing Address - Country:US
Mailing Address - Phone:912-231-8958
Mailing Address - Fax:912-234-7701
Practice Address - Street 1:102 OGLETHORPE PROFESSIONAL CT
Practice Address - Street 2:4
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3600
Practice Address - Country:US
Practice Address - Phone:912-231-8958
Practice Address - Fax:912-234-7701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA621610251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000510243CMedicaid