Provider Demographics
NPI:1376778001
Name:PHOEBE SUMTER MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:PHOEBE SUMTER MEDICAL CENTER, INC
Other - Org Name:PHOEBE SUMTER ELLAVILLE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNNEBORG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-931-1191
Mailing Address - Street 1:PO BOX 65
Mailing Address - Street 2:
Mailing Address - City:ELLAVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31806-9228
Mailing Address - Country:US
Mailing Address - Phone:229-937-5321
Mailing Address - Fax:229-934-2232
Practice Address - Street 1:339 S BROAD ST
Practice Address - Street 2:
Practice Address - City:ELLAVILLE
Practice Address - State:GA
Practice Address - Zip Code:31806-3304
Practice Address - Country:US
Practice Address - Phone:229-937-5321
Practice Address - Fax:229-937-2232
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOEBE SUMTER MEDICAL CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-26
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003112355AMedicaid
GA11-3403Medicare PIN