Basic Information
| Provider Information | |||||||||
| NPI: | 1053777920 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRASELTON GAINESVILLE EMERGENCY DEPARTMENT PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 80044 | ||||||||
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| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191011044 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 743 SPRING ST NE | ||||||||
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| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4694012386 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2016 | ||||||||
| LastUpdateDate: | 01/08/2016 | ||||||||
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| AuthorizedOfficialLastName: | HARKRIDER | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4694012386 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.