Provider Demographics
NPI:1215911672
Name:HERITAGE INTERNAL MEDICINE, INC.
Entity type:Organization
Organization Name:HERITAGE INTERNAL MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:GARLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-754-3287
Mailing Address - Street 1:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:DEMOREST
Mailing Address - State:GA
Mailing Address - Zip Code:30535-0579
Mailing Address - Country:US
Mailing Address - Phone:706-754-3287
Mailing Address - Fax:706-754-7646
Practice Address - Street 1:396 HWY 441 N
Practice Address - Street 2:SUITE A
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-0579
Practice Address - Country:US
Practice Address - Phone:706-754-3287
Practice Address - Fax:706-754-7646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA22813207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA005-114-09BMedicaid
GA52415033 002OtherBCBS PROVIDER NUMBER
GAD45912Medicare UPIN
GA005-114-09BMedicaid