Provider Demographics
NPI:1114077401
Name:FORDHAM, CASEY LEE (R MR)
Entity Type:Individual
Prefix:MR
First Name:CASEY
Middle Name:LEE
Last Name:FORDHAM
Suffix:
Gender:M
Credentials:R MR
Other - Prefix:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:219 LAKE LILLIAN DR
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069-9789
Mailing Address - Country:US
Mailing Address - Phone:478-988-9701
Mailing Address - Fax:
Practice Address - Street 1:1504 HARDEMAN AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1416
Practice Address - Country:US
Practice Address - Phone:478-745-3135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
347107247100000X, 2471M1202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
Not Answered2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance Imaging