Provider Demographics
NPI:1871697508
Name:PHOEBE PUTNEY MEMORIAL HOSPITAL, INC.
Entity type:Organization
Organization Name:PHOEBE PUTNEY MEMORIAL HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-312-4068
Mailing Address - Street 1:427 W THIRD AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1943
Mailing Address - Country:US
Mailing Address - Phone:229-312-0042
Mailing Address - Fax:229-312-0045
Practice Address - Street 1:427 W THIRD AVENUE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701
Practice Address - Country:US
Practice Address - Phone:229-312-0042
Practice Address - Fax:229-312-0045
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOEBE PUTNEY MEMORIAL HOSPITAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-12
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA16760332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00932489AMedicaid
GA00932489BMedicaid
GA00932489AMedicaid