Healthcare Provider Details

I. General information

NPI: 1609262773
Provider Name (Legal Business Name): TIFT COUNTY HOSPITAL AUTHORITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2015
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 JOHN ORR DR
TIFTON GA
31794-3682
US

IV. Provider business mailing address

907 18TH ST E SUITE 150
TIFTON GA
31794-3643
US

V. Phone/Fax

Practice location:
  • Phone: 229-386-5222
  • Fax:
Mailing address:
  • Phone: 229-386-5222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number015420
License Number StateGA

VIII. Authorized Official

Name: LINDA A WILSON
Title or Position: VP PHYSICIAN SERVICES
Credential:
Phone: 229-353-3403