Provider Demographics
NPI:1972796803
Name:THE BRASELTON CLINIC
Entity type:Organization
Organization Name:THE BRASELTON CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-533-8406
Mailing Address - Street 1:601 S ENOTA DR NE
Mailing Address - Street 2:SUITE Q
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2400
Mailing Address - Country:US
Mailing Address - Phone:770-533-8400
Mailing Address - Fax:770-533-8409
Practice Address - Street 1:5875 THOMPSON MILL RD
Practice Address - Street 2:STE. 200
Practice Address - City:HOSCHTON
Practice Address - State:GA
Practice Address - Zip Code:30548-4001
Practice Address - Country:US
Practice Address - Phone:770-965-2022
Practice Address - Fax:770-967-6325
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST GEORGIA PRIMARY CARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-23
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511G700042OtherMEDICARE GROUP ID