MEDICARE: PHOEBE NEUROLOGY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	064610	GA

General Provider Information

NPI Number	:	1407176647
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOEBE NEUROLOGY

Provider Business Mailing Address
First Line	:	2709 MEREDYTH DR
Second Line	:	STE 230
City	:	ALBANY
State	:	GA
Zip	:	31707-0222
Country	:	US
Telephone Number	:	229-312-5080
Fax Number	:	229-312-5085

Provider Business Practice Location Address
First Line	:	2709 MEREDYTH DR
Second Line	:	STE 230
City	:	ALBANY
State	:	GA
Zip	:	31707-0218
Country	:	US
Telephone Number	:	229-312-5080
Fax Number	:	229-312-5085

Authorized Official
Title or Position	:	SR VP PHYS PRACTICES
Name	:	ROBERT LAGESSE
Credential	:
Telephone Number	:	229-312-1000

Provider Enumeration Date	:	06/10/2010
Last Update Date	:	06/10/2010

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