Provider Demographics
NPI:1336215615
Name:PHOEBE PUTNEY MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:PHOEBE PUTNEY MEMORIAL HOSPITAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AVP, BUSINESS AFFAIRS
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUEDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-312-4268
Mailing Address - Street 1:417 W 3RD AVE
Mailing Address - Street 2:PO BOX 3770
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1943
Mailing Address - Country:US
Mailing Address - Phone:229-312-4268
Mailing Address - Fax:229-312-4316
Practice Address - Street 1:417 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1943
Practice Address - Country:US
Practice Address - Phone:229-312-4268
Practice Address - Fax:229-312-4316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00001482JMedicaid