# PRIME HEALTHCARE FOUNDATION - SOUTHERN REGIONAL, LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Southern Regional Medical Center
- **Organization subpart:** No

## Provider details

- **NPI number:** 1154795581
- **Authorized official:** CHRISTOPHER DOAN (MANAGING ASSOCIATE GENERAL COUNSEL)
- **Authorized official phone:** (310) 259-4706

## Contact information

- **Practice address:** 11 UPPER RIVERDALE RD SW, RIVERDALE, GA 30274-2615
- **Practice address phone:** (770) 991-8000
- **Mailing address:** 11 UPPER RIVERDALE RD SW, RIVERDALE, GA 30274-2615
- **Mailing address phone:** (770) 991-8000

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207RC0000X | Cardiovascular Disease Physician | — | — | — |
| 282N00000X | General Acute Care Hospital | 031-442 | GA | Yes |

## Other

- **Enumeration date:** 11/23/2015
- **Last updated:** 09/14/2021

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 00000404A | — | GA |