Basic Information
| Provider Information | |||||||||
| NPI: | 1912068503 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TIFTAREA UROLOGY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1815 OLD OCILLA RD | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317941617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293913535 | ||||||||
| FaxNumber: | 2293913529 | ||||||||
| Practice Location | |||||||||
| Address1: | 1815 OLD OCILLA RD | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317941617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293913535 | ||||||||
| FaxNumber: | 2293913529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 05/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | PETERS | ||||||||
| AuthorizedOfficialFirstName: | JEFFRY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2293913535 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 040514 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.