Provider Demographics
NPI:1942735287
Name:DEAN FORDHAM
Entity Type:Organization
Organization Name:DEAN FORDHAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:T
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-442-1983
Mailing Address - Street 1:6886 SHADYBROOK TRL
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-3802
Mailing Address - Country:US
Mailing Address - Phone:706-682-0422
Mailing Address - Fax:
Practice Address - Street 1:6886 SHADYBROOK TRL
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-3802
Practice Address - Country:US
Practice Address - Phone:706-682-0422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA56623207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty