Provider Demographics
NPI:1245419183
Name:RODNEY D. TYSON MD,PC
Entity Type:Organization
Organization Name:RODNEY D. TYSON MD,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:TYSON
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:229-896-3424
Mailing Address - Street 1:103 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:ADEL
Mailing Address - State:GA
Mailing Address - Zip Code:31620-1504
Mailing Address - Country:US
Mailing Address - Phone:229-896-3424
Mailing Address - Fax:229-896-3838
Practice Address - Street 1:103 JAMES ST
Practice Address - Street 2:
Practice Address - City:ADEL
Practice Address - State:GA
Practice Address - Zip Code:31620-1504
Practice Address - Country:US
Practice Address - Phone:229-896-3424
Practice Address - Fax:229-896-3838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-28
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038994261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00703425AMedicaid
GA507222OtherBCBS PROVIDER NUMBER
GA00703425AMedicaid
GA510G700693Medicare PIN