Healthcare Provider Details

I. General information

NPI: 1184705097
Provider Name (Legal Business Name): JIAN LI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 US HIGHWAY 41 N
TIFTON GA
31794-2749
US

IV. Provider business mailing address

907 18TH ST E STE 400
TIFTON GA
31794-3684
US

V. Phone/Fax

Practice location:
  • Phone: 229-391-4100
  • Fax:
Mailing address:
  • Phone: 229-353-3422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number061794
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMD.201018
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number061794
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: