Provider Demographics
NPI:1245410307
Name:FITZGERALD OB/GYN
Entity Type:Organization
Organization Name:FITZGERALD OB/GYN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:LEANNE
Authorized Official - Last Name:PARHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-424-7685
Mailing Address - Street 1:PO BOX 1027
Mailing Address - Street 2:
Mailing Address - City:FITZGERALD
Mailing Address - State:GA
Mailing Address - Zip Code:31750-1027
Mailing Address - Country:US
Mailing Address - Phone:229-426-7685
Mailing Address - Fax:
Practice Address - Street 1:808 S GRANT ST
Practice Address - Street 2:
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750-3703
Practice Address - Country:US
Practice Address - Phone:229-426-7685
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046468207V00000X
GARN101986 NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA173496898BMedicaid
GA000837669AMedicaid
GAQ03884Medicare UPIN
GA173496898BMedicaid
GA50BBKJPMedicare PIN
GAH01160Medicare UPIN