Provider Demographics
NPI:1487667234
Name:FOGAM, ERIC G (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:G
Last Name:FOGAM
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:PO BOX 879
Mailing Address - Street 2:
Mailing Address - City:SWAINSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30401-0879
Mailing Address - Country:US
Mailing Address - Phone:478-289-1349
Mailing Address - Fax:478-289-1300
Practice Address - Street 1:117 KITE RD
Practice Address - Street 2:
Practice Address - City:SWAINSBORO
Practice Address - State:GA
Practice Address - Zip Code:30401-3231
Practice Address - Country:US
Practice Address - Phone:478-289-1349
Practice Address - Fax:478-289-1300
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA47902207PE0004X
GA047902207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH39816Medicare UPIN