Provider Demographics
NPI:1114021847
Name:PHOEBE PUTNEY MEMORIAL HOSPITAL, INC
Entity Type:Organization
Organization Name:PHOEBE PUTNEY MEMORIAL HOSPITAL, INC
Other - Org Name:PHOEBE ORTHOPEDIC SUPPLIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR V.P./CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:LOUDERMILK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-312-4068
Mailing Address - Street 1:417 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31702-1828
Mailing Address - Country:US
Mailing Address - Phone:229-312-8600
Mailing Address - Fax:229-312-8624
Practice Address - Street 1:417 3RD AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31702-1828
Practice Address - Country:US
Practice Address - Phone:229-312-8600
Practice Address - Fax:229-312-8624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA16760332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000628592BMedicaid
0734210006Medicare NSC