Provider Demographics
NPI:1790932655
Name:SOUTHERN HEALTH CORP OF ELLIJAY
Entity Type:Organization
Organization Name:SOUTHERN HEALTH CORP OF ELLIJAY
Other - Org Name:INTERNAL MEDICINE OF NORTH GEORGIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:SELF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-276-4741
Mailing Address - Street 1:PO BOX 1019
Mailing Address - Street 2:
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-0013
Mailing Address - Country:US
Mailing Address - Phone:706-635-5177
Mailing Address - Fax:706-635-5183
Practice Address - Street 1:190 HOSPITAL CIR
Practice Address - Street 2:
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-9694
Practice Address - Country:US
Practice Address - Phone:706-698-7400
Practice Address - Fax:706-698-7401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-22
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010925207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAHOSP34Medicare PIN