Healthcare Provider Details

I. General information

NPI: 1124488291
Provider Name (Legal Business Name): ELBERT MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2016
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 LAUREL DR
ELBERTON GA
30635-1842
US

IV. Provider business mailing address

4 MEDICAL DR
ELBERTON GA
30635-1830
US

V. Phone/Fax

Practice location:
  • Phone: 706-213-2579
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: BRANDON CLARY
Title or Position: CEO
Credential:
Phone: 706-213-2535