Provider Demographics
NPI:1588755607
Name:TIAN, LICHENG (MD/PHD)
Entity type:Individual
Prefix:DR
First Name:LICHENG
Middle Name:
Last Name:TIAN
Suffix:
Gender:M
Credentials:MD/PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:758 BRADBERRY CRK
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-4050
Mailing Address - Country:US
Mailing Address - Phone:706-228-4557
Mailing Address - Fax:
Practice Address - Street 1:3405 MIKE PADGETT HWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-3815
Practice Address - Country:US
Practice Address - Phone:706-792-7021
Practice Address - Fax:706-792-7138
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047853207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
11SCDQKMedicare ID - Type Unspecified
H21937Medicare UPIN