NPIMap

Organization Active NPI

Elbert Memorial Hospital

  • Obstetrics & Gynecology Physician
  • Elberton, GA
National Provider Identifier
1124488291
Registry record updated Mar 24, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Obstetrics & Gynecology PhysicianTaxonomy code 207V00000X
Legal business name
ELBERT MEMORIAL HOSPITAL
Practice address
46 Laurel Dr
Elberton, GA 30635-1842
Phone
(706) 213-2579
NPI assigned
Mar 2, 2016
Organization subpart
Yes
Parent organization
ELBERT MEMORIAL HOSPITALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 24, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Brandon Clary
Title
Ceo
Phone
(706) 213-2535

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Obstetrics & Gynecology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207V00000X Primary
Otolaryngology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Y00000X
Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208600000X

Addresses

Primary practice location

46 Laurel Dr
Elberton, GA 30635-1842

Mailing address

4 Medical Dr
Elberton, GA 30635-1830

Other names 1

  • Lake Russell Specialty Healthcare Services Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20160323000602 GA Part B Supplier - Clinic/Group Practice 6800889841 Receives reassigned benefits from 5 practitioners
Practice locations: Elberton, GA

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Elbert Mem Hospital5 organizations share this tax ID, including this one
Part of
Elbert Mem Hospital

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1456876800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1458777600000",
    "number": "1124488291",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4 MEDICAL DR",
            "city": "ELBERTON",
            "state": "GA",
            "postal_code": "306351830"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "46 LAUREL DR",
            "city": "ELBERTON",
            "state": "GA",
            "postal_code": "306351842",
            "telephone_number": "706-213-2579"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ELBERT MEMORIAL HOSPITAL",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ELBERT MEMORIAL HOSPITAL",
        "enumeration_date": "2016-03-02",
        "last_updated": "2016-03-24",
        "status": "A",
        "authorized_official_last_name": "CLARY",
        "authorized_official_first_name": "BRANDON",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "706-213-2535"
    },
    "taxonomies": [
        {
            "code": "207V00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Obstetrics & Gynecology",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207Y00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Otolaryngology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208600000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Surgery",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lake Russell Specialty Healthcare Services",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Elberton, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 24, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.