Basic Information
| Provider Information | |||||||||
| NPI: | 1962678524 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HABERSHAM INTERNAL MEDICINE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | HABERSHAM INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 699 | ||||||||
| Address2: | |||||||||
| City: | DEMOREST | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067548066 | ||||||||
| FaxNumber: | 7067548086 | ||||||||
| Practice Location | |||||||||
| Address1: | 870 AUSTIN DRIVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | DEMOREST | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067548066 | ||||||||
| FaxNumber: | 7067548086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2008 | ||||||||
| LastUpdateDate: | 02/14/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRAY | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | ALLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 7067548066 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 026464 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 207R00000X | 026464 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | GRP144 | 01 | GA | MEDICARE GROUP NUMBER | OTHER | 000406062A | 05 | GA | MEDICAID |