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General NPI Number Information
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NPI Number | 1942735287
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Entity Type | Organization
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Legal Business Name | DEAN FORDHAM
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Dates
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Enumeration Date | 04/24/2017
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Last Update Date | 04/24/2017
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Provider Practice Location Address
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Address Line | 6886 SHADYBROOK TRL
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City | COLUMBUS
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State | GA
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Zip | 31904-3802
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Country | US
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Telephone | 706-682-0422
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Fax |
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Provider Business Mailing Address
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Address Line | 6886 SHADYBROOK TRL
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City | COLUMBUS
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State | GA
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Zip | 31904-3802
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Country | US
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Telephone | 706-682-0422
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. TIFFANY T BYRD
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Credential | MD
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Telephone | 706-442-1983
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 56623
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License Number State | GA
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