Basic Information
| Provider Information | |||||||||
| NPI: | 1013999291 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOREISH | ||||||||
| FirstName: | HISHAM | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2416 BRYNLYN WOODS DR NE | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300131426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709227664 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 150 GILBREATH DR | ||||||||
| Address2: | |||||||||
| City: | ONEONTA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351212827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2052743004 | ||||||||
| FaxNumber: | 2052743002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 03/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 46854 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 051531620 | 01 | AL | BCBS | OTHER | 009914077 | 05 | AL | MEDICAID | 051545800 | 01 | AL | BCBS | OTHER | 051531620 | 05 | AL | MEDICAID | 051557081 | 05 | AL | MEDICAID | 7903244 | 01 | AL | AETNA | OTHER | 051531845 | 01 | AL | BCBS | OTHER |