Provider Demographics
NPI:1891863569
Name:THE MEDICAL CENTER OF ELBERTON, LLP
Entity Type:Organization
Organization Name:THE MEDICAL CENTER OF ELBERTON, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:S
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-283-3315
Mailing Address - Street 1:109 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:ELBERTON
Mailing Address - State:GA
Mailing Address - Zip Code:30635-1705
Mailing Address - Country:US
Mailing Address - Phone:706-283-3315
Mailing Address - Fax:706-283-2159
Practice Address - Street 1:109 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ELBERTON
Practice Address - State:GA
Practice Address - Zip Code:30635-1705
Practice Address - Country:US
Practice Address - Phone:706-283-3315
Practice Address - Fax:706-283-2159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11-3958261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA85000124GMedicaid
GAGRP1194Medicare ID - Type UnspecifiedMEDICARE PART B PROVIDER
GA11-3958Medicare Oscar/Certification