MEDICARE: PHG MCRAE LLC

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	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1962251645
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHG MCRAE LLC

Provider Business Mailing Address
First Line	:	160 S FIRST AVE
Second Line	:
City	:	MC RAE
State	:	GA
Zip	:	31055-3334
Country	:	US
Telephone Number	:	229-868-6473
Fax Number	:	229-868-2981

Provider Business Practice Location Address
First Line	:	160 S FIRST AVE
Second Line	:
City	:	MC RAE
State	:	GA
Zip	:	31055-3334
Country	:	US
Telephone Number	:	229-868-6473
Fax Number	:	229-868-2981

Authorized Official
Title or Position	:	MEMBER
Name	:	DAVID LEMCKE
Credential	:
Telephone Number	:	678-808-4071

Provider Enumeration Date	:	05/15/2024
Last Update Date	:	05/15/2024

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Directions to “PHG MCRAE LLC ” Practice Location

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