Healthcare Provider Details

I. General information

NPI: 1598945347
Provider Name (Legal Business Name): FT GAINES MEDICAL ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 07/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 HARTFORD RD E
FORT GAINES GA
39851-3638
US

IV. Provider business mailing address

PO BOX 489
CUTHBERT GA
39840-0489
US

V. Phone/Fax

Practice location:
  • Phone: 229-768-2633
  • Fax: 229-768-2263
Mailing address:
  • Phone: 229-768-2633
  • Fax: 229-768-2263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ABDOLLATIF S GHIATHI
Title or Position: OWNER
Credential: DO
Phone: 334-793-8087