Provider Demographics
NPI:1124154794
Name:FAMILY PRACTICE OF HABERSHAM PC
Entity type:Organization
Organization Name:FAMILY PRACTICE OF HABERSHAM PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:C
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-754-1252
Mailing Address - Street 1:PO BOX 1779
Mailing Address - Street 2:
Mailing Address - City:DEMOREST
Mailing Address - State:GA
Mailing Address - Zip Code:30535-1779
Mailing Address - Country:US
Mailing Address - Phone:706-754-5511
Mailing Address - Fax:706-754-5577
Practice Address - Street 1:590 HISTORIC HWY 441 N
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-1779
Practice Address - Country:US
Practice Address - Phone:706-754-5511
Practice Address - Fax:706-754-5577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032741261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3078OtherMEDICARE GRP #