Basic Information
| Provider Information | |||||||||
| NPI: | 1194792929 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCEACHIN | ||||||||
| FirstName: | FORTE | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 907 18TH ST E STE 400 | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317943684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293829733 | ||||||||
| FaxNumber: | 2293876161 | ||||||||
| Practice Location | |||||||||
| Address1: | 1007 GREENFIELD DR | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317943795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293829733 | ||||||||
| FaxNumber: | 2293876161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 044017 | GA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00759426A | 05 | GA | MEDICAID |