MEDICARE: DR. ANDREW TICE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician	020838	GA

General Provider Information

NPI Number	:	1033197579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANDREW TICE MD

Provider Business Mailing Address
First Line	:	1136 JACKSON SPRINGS RD
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31211-1435
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1136 JACKSON SPRINGS RD
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31211-1435
Country	:	US
Telephone Number	:	478-746-9797
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2006
Last Update Date	:	07/08/2007

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