Provider Demographics
NPI:1114114055
Name:DOUGLAS MEDICAL SPECIALIST
Entity Type:Organization
Organization Name:DOUGLAS MEDICAL SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:G
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-384-3338
Mailing Address - Street 1:134 E FLEETWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WILLACOOCHEE
Mailing Address - State:GA
Mailing Address - Zip Code:31650
Mailing Address - Country:US
Mailing Address - Phone:912-384-3338
Mailing Address - Fax:912-383-6365
Practice Address - Street 1:134 E FLEETWOOD AVE
Practice Address - Street 2:
Practice Address - City:WILLACOOCHEE
Practice Address - State:GA
Practice Address - Zip Code:31650
Practice Address - Country:US
Practice Address - Phone:912-384-3338
Practice Address - Fax:912-383-6365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056658207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1326031865OtherNPI
GA1891815924OtherNPI
GA1225021678OtherNPI
GA1750374294OtherNPI
G29391Medicare UPIN
P28327Medicare UPIN
Q46706Medicare UPIN
GA1225021678OtherNPI
F23558Medicare UPIN