Healthcare Provider Details

I. General information

NPI: 1124093869
Provider Name (Legal Business Name): FESTUS I ENUMAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 08/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1629 10TH AVE STE A
COLUMBUS GA
31901
US

IV. Provider business mailing address

1629 10TH AVE STE A
COLUMBUS GA
31901
US

V. Phone/Fax

Practice location:
  • Phone: 706-322-7441
  • Fax: 706-322-0165
Mailing address:
  • Phone: 706-322-7441
  • Fax: 706-322-0165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number027809
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: