Provider Demographics
NPI:1720365018
Name:THOMAS D FAUSETT JR MD PC
Entity Type:Organization
Organization Name:THOMAS D FAUSETT JR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:FAUSETT
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:229-896-7007
Mailing Address - Street 1:707 N PARRISH AVE
Mailing Address - Street 2:
Mailing Address - City:ADEL
Mailing Address - State:GA
Mailing Address - Zip Code:31620-1521
Mailing Address - Country:US
Mailing Address - Phone:229-896-7007
Mailing Address - Fax:229-896-7627
Practice Address - Street 1:707 N PARRISH AVE
Practice Address - Street 2:
Practice Address - City:ADEL
Practice Address - State:GA
Practice Address - Zip Code:31620-1521
Practice Address - Country:US
Practice Address - Phone:229-896-7007
Practice Address - Fax:229-896-7627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046090207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty