Provider Demographics
NPI:1003023987
Name:BREMEN FAMILY MEDICINE
Entity Type:Organization
Organization Name:BREMEN FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOLLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-537-1960
Mailing Address - Street 1:327 OLD BUSHMILL RD
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:GA
Mailing Address - Zip Code:30110-3835
Mailing Address - Country:US
Mailing Address - Phone:770-537-1960
Mailing Address - Fax:770-537-1901
Practice Address - Street 1:308 CARROLLTON ST
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:GA
Practice Address - Zip Code:30110-2015
Practice Address - Country:US
Practice Address - Phone:770-537-1960
Practice Address - Fax:770-537-1901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034852208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00478552HMedicaid
GA08BBRSDMedicare ID - Type Unspecified
GA00478552HMedicaid