1134225501 NPI number — TIFTON FAMILY MEDICINE, PC

Table of content: (NPI 1134225501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134225501 NPI number — TIFTON FAMILY MEDICINE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIFTON FAMILY MEDICINE, PC
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:
1134225501
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3025 BRECKINRIDGE BLVD
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30096
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-226-0022
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
902 18TH ST EAST
Provider Second Line Business Practice Location Address:
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:
229-382-6414
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERTS
Authorized Official First Name:
MARCUS
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
229-382-6414

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  035986 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CL2838 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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