Healthcare Provider Details

I. General information

NPI: 1639157431
Provider Name (Legal Business Name): PHOEBE WORTH MEDICAL CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 S ISABELLA ST
SYLVESTER GA
31791-7554
US

IV. Provider business mailing address

807 S ISABELLA ST P.O. BOX 545
SYLVESTER GA
31791-7554
US

V. Phone/Fax

Practice location:
  • Phone: 229-777-4514
  • Fax: 229-776-7062
Mailing address:
  • Phone: 229-777-4514
  • Fax: 229-776-7062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000490
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerBLUE CROSS
# 2
Identifier00002109A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer
# 3
IdentifierHOSP237
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerMEDICARE
# 4
Identifier017839800
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

Name: STACEY L FLYNT
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 229-777-4514