Provider Demographics
NPI:1033506340
Name:TIFT REGIONAL HEALTH SYSTEM INC
Entity Type:Organization
Organization Name:TIFT REGIONAL HEALTH SYSTEM INC
Other - Org Name:OCILLA PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:DORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-353-6104
Mailing Address - Street 1:PO BOX 2650
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31793-2650
Mailing Address - Country:US
Mailing Address - Phone:229-353-3422
Mailing Address - Fax:
Practice Address - Street 1:813 N IRWIN AVE
Practice Address - Street 2:
Practice Address - City:OCILLA
Practice Address - State:GA
Practice Address - Zip Code:31774-3757
Practice Address - Country:US
Practice Address - Phone:229-468-7323
Practice Address - Fax:229-468-7320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-24
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA064200208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty