1639157431 NPI number — PHOEBE WORTH MEDICAL CENTER, INC

Table of content: (NPI 1639157431)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639157431 NPI number — PHOEBE WORTH MEDICAL CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOEBE WORTH 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:
Provider Other Organization Name Type Code:
6
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:
1639157431
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
807 S ISABELLA ST
Provider Second Line Business Mailing Address:
P.O. BOX 545
Provider Business Mailing Address City Name:
SYLVESTER
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31791-7554
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-777-4514
Provider Business Mailing Address Fax Number:
229-776-7062

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
807 S ISABELLA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYLVESTER
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31791-7554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-777-4514
Provider Business Practice Location Address Fax Number:
229-776-7062
Provider Enumeration Date:
01/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FLYNT
Authorized Official First Name:
STACEY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
BUSINESS OFFICE MANAGER
Authorized Official Telephone Number:
229-777-4514

Provider Taxonomy Codes

  • Taxonomy code: 282NC0060X , 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: 000490 . This is a "BLUE CROSS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00002109A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: HOSP237 . This is a "MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 017839800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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