Provider Demographics
NPI:1417022070
Name:TISON, JAMES HARMON (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:HARMON
Last Name:TISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1085 PLAZA AVE
Mailing Address - Street 2:
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-9102
Mailing Address - Country:US
Mailing Address - Phone:478-559-1386
Mailing Address - Fax:478-559-1388
Practice Address - Street 1:1085 PLAZA AVE STE B
Practice Address - Street 2:
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-9102
Practice Address - Country:US
Practice Address - Phone:478-374-5582
Practice Address - Fax:478-374-3756
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA015516207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
52044058OtherBCBS
407111537OtherRR MCARE
GA000091011AMedicaid
D31029Medicare UPIN