Healthcare Provider Details

I. General information

NPI: 1033506340
Provider Name (Legal Business Name): TIFT REGIONAL HEALTH SYSTEM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 N IRWIN AVE
OCILLA GA
31774-3757
US

IV. Provider business mailing address

PO BOX 2650
TIFTON GA
31793-2650
US

V. Phone/Fax

Practice location:
  • Phone: 229-468-7323
  • Fax: 229-468-7320
Mailing address:
  • Phone: 229-353-3422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number064200
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: CHRISTOPHER DORMAN
Title or Position: PRESIDENT/CEO
Credential:
Phone: 229-353-6104