Provider Demographics
NPI:1821293788
Name:PHOEBE PUTNEY MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:PHOEBE PUTNEY MEMORIAL HOSPITAL, INC.
Other - Org Name:PHOEBE FAMILY MEDICAL CENTER - CAMILLA
Other - Org Type:Other Name
Authorized Official - Title/Position:SR VP PHYSICIAN SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LAGESSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-312-4055
Mailing Address - Street 1:PO BOX 3109
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31706-3109
Mailing Address - Country:US
Mailing Address - Phone:229-312-5800
Mailing Address - Fax:229-312-5853
Practice Address - Street 1:48 US HIGHWAY 19 S
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-1960
Practice Address - Country:US
Practice Address - Phone:229-336-5208
Practice Address - Fax:229-336-8260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP1226OtherMEDICARE GROUP
GA000001482MMedicaid
GA000001482MMedicaid