Provider Demographics
NPI:1992084644
Name:PHOEBE DORMINY FAMILY CARE
Entity type:Organization
Organization Name:PHOEBE DORMINY FAMILY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VP PHYSICIAN PRACTICES
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LAGESSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-312-1000
Mailing Address - Street 1:110 NORMAN DORMINY DR
Mailing Address - Street 2:
Mailing Address - City:FITZGERALD
Mailing Address - State:GA
Mailing Address - Zip Code:31750-8858
Mailing Address - Country:US
Mailing Address - Phone:229-312-5800
Mailing Address - Fax:
Practice Address - Street 1:110 NORMAN DORMINY DR
Practice Address - Street 2:
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750-8858
Practice Address - Country:US
Practice Address - Phone:229-312-5800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOEBE PHYSICIAN GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center