Provider Demographics
NPI:1013315605
Name:TIFT COUNTY HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:TIFT COUNTY HOSPITAL AUTHORITY
Other - Org Name:FITZGERALD PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP PHYSICIAN SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-353-3403
Mailing Address - Street 1:907 18TH ST E
Mailing Address - Street 2:SUITE 150
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3643
Mailing Address - Country:US
Mailing Address - Phone:229-423-2400
Mailing Address - Fax:
Practice Address - Street 1:246 BEN HILL DRIVE
Practice Address - Street 2:
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750
Practice Address - Country:US
Practice Address - Phone:229-423-2400
Practice Address - Fax:229-423-2472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-12
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030071207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty