1962678524 NPI number — HABERSHAM INTERNAL MEDICINE

Table of content: (NPI 1962678524)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962678524 NPI number — HABERSHAM INTERNAL MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HABERSHAM INTERNAL MEDICINE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HABERSHAM INTERNAL MEDICINE
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962678524
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 699
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEMOREST
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-754-8066
Provider Business Mailing Address Fax Number:
706-754-8086

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
870 AUSTIN DRIVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
DEMOREST
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-754-8066
Provider Business Practice Location Address Fax Number:
706-754-8086
Provider Enumeration Date:
05/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BRAY
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
706-754-8066

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  026464 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 026464 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GRP144 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000406062A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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