Provider Demographics
NPI:1689859720
Name:FAMILY HEALTH CENTER OF TIFTAREA
Entity Type:Organization
Organization Name:FAMILY HEALTH CENTER OF TIFTAREA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHAROLETT
Authorized Official - Middle Name:MITTIE
Authorized Official - Last Name:ENGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-387-9205
Mailing Address - Street 1:2016 PINEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3035
Mailing Address - Country:US
Mailing Address - Phone:229-387-9205
Mailing Address - Fax:229-387-9254
Practice Address - Street 1:2016 PINEVIEW AVE
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3035
Practice Address - Country:US
Practice Address - Phone:229-387-9205
Practice Address - Fax:229-387-9254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049713207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH43121Medicare UPIN
GAGRP6144Medicare PIN