Healthcare Provider Details

I. General information

NPI: 1306849831
Provider Name (Legal Business Name): J SCOTT BRICKMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2005
Last Update Date: 03/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4279 FOREST LAKE DR W
TIFTON GA
31794-2352
US

IV. Provider business mailing address

4279 FOREST LAKE DR W
TIFTON GA
31794-2352
US

V. Phone/Fax

Practice location:
  • Phone: 229-848-6058
  • Fax:
Mailing address:
  • Phone: 229-848-6058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number45042
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: