Healthcare Provider Details

I. General information

NPI: 1245410307
Provider Name (Legal Business Name): FITZGERALD OB/GYN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 S GRANT ST
FITZGERALD GA
31750-3703
US

IV. Provider business mailing address

PO BOX 1027
FITZGERALD GA
31750-1027
US

V. Phone/Fax

Practice location:
  • Phone: 229-426-7685
  • Fax:
Mailing address:
  • Phone: 229-426-7685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number046468
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN101986 NP
License Number StateGA

VIII. Authorized Official

Name: MRS. TONYA LEANNE PARHAM
Title or Position: OFFICE MANAGER
Credential:
Phone: 229-424-7685