1376778001 NPI number — PHOEBE SUMTER MEDICAL CENTER, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376778001 NPI number — PHOEBE SUMTER MEDICAL CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOEBE SUMTER MEDICAL CENTER, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PHOEBE SUMTER ELLAVILLE CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376778001
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 65
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLAVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31806-9228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-937-5321
Provider Business Mailing Address Fax Number:
229-934-2232

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
339 S BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLAVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31806-3304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-937-5321
Provider Business Practice Location Address Fax Number:
229-937-2232
Provider Enumeration Date:
05/26/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LUNNEBORG
Authorized Official First Name:
BRANDI
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
229-931-1191

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003112355A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com