Healthcare Provider Details

I. General information

NPI: 1205474954
Provider Name (Legal Business Name): TIFT REGIONAL HEALTH SYSTEM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2019
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1499 KENNEDY ROAD SUITE A
TIFTON GA
31794-4177
US

IV. Provider business mailing address

PO BOX 2650
TIFTON GA
31793-2650
US

V. Phone/Fax

Practice location:
  • Phone: 229-353-4243
  • Fax: 229-353-3673
Mailing address:
  • Phone: 229-353-3422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

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