Basic Information
| Provider Information | |||||||||
| NPI: | 1114915618 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORDYCE | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 307 E 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | CORDELE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310153208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292714656 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 910 N 5TH ST STE H | ||||||||
| Address2: | |||||||||
| City: | CORDELE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310153254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292762286 | ||||||||
| FaxNumber: | 2292762289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 01/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 047318 | GA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 047318 | 01 | GA | GA LIC | OTHER | 52728669 | 01 | GA | BLUE CROSS BLUE SHIELD | OTHER | 000849351B | 05 | GA | MEDICAID | BF5306558 | 01 | GA | DEA LIC | OTHER |