Provider Demographics
NPI:1598945347
Name:FT GAINES MEDICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:FT GAINES MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABDOLLATIF
Authorized Official - Middle Name:S
Authorized Official - Last Name:GHIATHI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:334-793-8087
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:CUTHBERT
Mailing Address - State:GA
Mailing Address - Zip Code:39840-0489
Mailing Address - Country:US
Mailing Address - Phone:229-768-2633
Mailing Address - Fax:229-768-2263
Practice Address - Street 1:106 HARTFORD RD E
Practice Address - Street 2:
Practice Address - City:FORT GAINES
Practice Address - State:GA
Practice Address - Zip Code:39851-3638
Practice Address - Country:US
Practice Address - Phone:229-768-2633
Practice Address - Fax:229-768-2263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG17338Medicare UPIN
GA511G700229Medicare PIN