Provider Demographics
NPI:1104099274
Name:PICKETT, SARA HARBIN (MD)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:HARBIN
Last Name:PICKETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:BASS
Other - Last Name:HARBIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:115 N CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:ADAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30103-2467
Practice Address - Country:US
Practice Address - Phone:470-601-5750
Practice Address - Fax:770-877-3655
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA066353208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003112032AMedicaid
GA202I378575Medicare PIN