Basic Information
| Provider Information | |||||||||
| NPI: | 1083622849 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALPHA INTERNAL MEDICINE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALPHA INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 142459 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302146515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707195490 | ||||||||
| FaxNumber: | 7707193113 | ||||||||
| Practice Location | |||||||||
| Address1: | 745 GLYNN ST S | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302142049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707195490 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 04/01/2014 | ||||||||
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| AuthorizedOfficialLastName: | HORTON | ||||||||
| AuthorizedOfficialFirstName: | BETSY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7707195490 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 055270 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 053123 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 047760 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 133V00000X | 720353 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 207R00000X | 040693 | GA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00753519B | 05 | GA | MEDICAID | 510368765A | 05 | GA | MEDICAID |