Provider Demographics
NPI:1871816918
Name:TIFT REGIONAL HEALTH SYSTEM, INC.
Entity Type:Organization
Organization Name:TIFT REGIONAL HEALTH SYSTEM, INC.
Other - Org Name:SOUTHWELL MEDICAL ADEL PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:DORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-353-6104
Mailing Address - Street 1:PO BOX 2650
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31793-2650
Mailing Address - Country:US
Mailing Address - Phone:229-353-3422
Mailing Address - Fax:
Practice Address - Street 1:172 MJ TAYLOR RD
Practice Address - Street 2:
Practice Address - City:ADEL
Practice Address - State:GA
Practice Address - Zip Code:31620-3497
Practice Address - Country:US
Practice Address - Phone:229-896-8500
Practice Address - Fax:229-896-8503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-03
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003109531AMedicaid
GA118528Medicare Oscar/Certification