Provider Demographics
NPI:1588872600
Name:DAHLONEGA INTERNAL MEDICINE
Entity type:Organization
Organization Name:DAHLONEGA INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:W
Authorized Official - Last Name:WHITFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-864-1580
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533-0002
Mailing Address - Country:US
Mailing Address - Phone:706-864-1580
Mailing Address - Fax:706-864-1587
Practice Address - Street 1:109 TIPTON DR
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-1604
Practice Address - Country:US
Practice Address - Phone:706-864-1580
Practice Address - Fax:706-864-1587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048130207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000909191BMedicaid
GAH37226Medicare UPIN
GAGRP6859Medicare ID - Type Unspecified