Healthcare Provider Details

I. General information

NPI: 1275690703
Provider Name (Legal Business Name): SOUTHERN HEALTH CORP OF ELLIJAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1362 S MAIN ST
ELLIJAY GA
30540-5410
US

IV. Provider business mailing address

PO BOX 2239
ELLIJAY GA
30540-0025
US

V. Phone/Fax

Practice location:
  • Phone: 706-276-4741
  • Fax: 706-276-4745
Mailing address:
  • Phone: 706-276-4741
  • Fax: 706-276-4745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code275N00000X
TaxonomyMedicare Defined Swing Bed Hospital Unit
License Number061-435
License Number StateGA

VIII. Authorized Official

Name: MS. DEBBIE SELF
Title or Position: CHIEF FINANCIAL OFFICER
Credential: CFO
Phone: 706-276-4741