=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962791491
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIFFANY FERN GARTRELL M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2011
-----------------------------------------------------
Last Update Date | 10/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1625 HOSPITAL SOUTH DR STE 150
-----------------------------------------------------
City | AUSTELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30106-8111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-732-6950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1625 AUSTELL ROAD
-----------------------------------------------------
City | AUSTELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-732-6950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 76036
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084F0202X
-----------------------------------------------------
Taxonomy Name | Forensic Psychiatry Physician
-----------------------------------------------------
License Number | 76036
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------