=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255364600
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARDIOLOGY SPECIALISTS OF GEORGIA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 907 18TH ST E SUITE 100
-----------------------------------------------------
City | TIFTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31794-3643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-391-9980
-----------------------------------------------------
Fax | 229-391-9984
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 907 18TH ST E SUITE 100
-----------------------------------------------------
City | TIFTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31794-3643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-391-9980
-----------------------------------------------------
Fax | 229-391-9984
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | DR. MICHAEL SCOTT FENSTER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 229-391-9980
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 057762
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------