Provider Demographics
NPI:1508896705
Name:TIFTAREA ENDOSCOPY CENTER, INC.
Entity Type:Organization
Organization Name:TIFTAREA ENDOSCOPY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-391-3625
Mailing Address - Street 1:907 E. 18TH STREET
Mailing Address - Street 2:SUITE 460
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794
Mailing Address - Country:US
Mailing Address - Phone:229-391-3625
Mailing Address - Fax:229-391-3639
Practice Address - Street 1:907 E. 18TH STREET
Practice Address - Street 2:SUITE 460
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794
Practice Address - Country:US
Practice Address - Phone:229-391-3625
Practice Address - Fax:229-391-3639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA136-156261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00818892AMedicaid
GA136156OtherDHR LICENSE
111145ASCAMedicare PIN