1053487462 NPI number — TIFTAREA CARDIOLOGY

Table of content: (NPI 1053487462)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053487462 NPI number — TIFTAREA CARDIOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIFTAREA CARDIOLOGY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053487462
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
907 E. 18TH ST
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
TIFTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31794
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-391-9980
Provider Business Mailing Address Fax Number:
229-391-9984

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
907 E. 18TH ST
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
TIFTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31794
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-391-9980
Provider Business Practice Location Address Fax Number:
229-391-9984
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HANCOCK
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
WALTER
Authorized Official Title or Position:
OWNER/MD
Authorized Official Telephone Number:
229-391-9980

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  047089 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: 047089 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000701269F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 256355379 . This is a "TRICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 945232 . This is a "BCBS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: CG8763 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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