Basic Information
| Provider Information | |||||||||
| NPI: | 1053933754 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TIFT REGIONAL HEALTH SYSTEM INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHWELL NEPHROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2650 | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317932650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293533422 | ||||||||
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| Practice Location | |||||||||
| Address1: | 39 KENT RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317941697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293914310 | ||||||||
| FaxNumber: | 2293914243 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2020 | ||||||||
| LastUpdateDate: | 06/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | DORMAN | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 2293536104 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.