Healthcare Provider Details

I. General information

NPI: 1659624666
Provider Name (Legal Business Name): TIFTAREA SURGICAL PARTNERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2012
Last Update Date: 03/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 JOHN ORR DR SUITE H
TIFTON GA
31794-3682
US

IV. Provider business mailing address

PO BOX 629
PERRY GA
31069-0629
US

V. Phone/Fax

Practice location:
  • Phone: 229-387-1185
  • Fax:
Mailing address:
  • Phone: 229-387-1185
  • Fax: 229-382-6191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DREW DORMINEY
Title or Position: ADMINISTRATOR
Credential:
Phone: 229-387-1185