Basic Information
| Provider Information | |||||||||
| NPI: | 1659624666 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TIFTAREA SURGICAL PARTNERS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 629 | ||||||||
| Address2: | |||||||||
| City: | PERRY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310690629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293871185 | ||||||||
| FaxNumber: | 2293826191 | ||||||||
| Practice Location | |||||||||
| Address1: | 1610 JOHN ORR DR | ||||||||
| Address2: | SUITE H | ||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317943682 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293871185 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2012 | ||||||||
| LastUpdateDate: | 03/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | DORMINEY | ||||||||
| AuthorizedOfficialFirstName: | DREW | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2293871185 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.