Provider Demographics
NPI:1043577265
Name:PUTNAM GENERAL HOSPITAL MEDICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:PUTNAM GENERAL HOSPITAL MEDICAL ASSOCIATES, LLC
Other - Org Name:PGH MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:M
Authorized Official - Last Name:OGLESBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-923-2002
Mailing Address - Street 1:101 LAKE OCONEE PKWY
Mailing Address - Street 2:
Mailing Address - City:EATONTON
Mailing Address - State:GA
Mailing Address - Zip Code:31024-6054
Mailing Address - Country:US
Mailing Address - Phone:706-923-2002
Mailing Address - Fax:
Practice Address - Street 1:1000 COWLES CLINIC WAY
Practice Address - Street 2:STE W-2
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-4539
Practice Address - Country:US
Practice Address - Phone:706-999-0270
Practice Address - Fax:706-999-0274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty