Basic Information
| Provider Information | |||||||||
| NPI: | 1003937723 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHOEBE PUTNEY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PHOEBE FAMILY MEDICINE- LEESBURG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2548 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317022548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293125870 | ||||||||
| FaxNumber: | 2293125853 | ||||||||
| Practice Location | |||||||||
| Address1: | 1390 US HIGHWAY 19 S | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317634831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298897490 | ||||||||
| FaxNumber: | 2298897495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MIDDLETON | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PHYSICIAN SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 2293124055 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.