Provider Demographics
NPI:1073709218
Name:DANIELSVILLE FAMILY PRACTICE
Entity Type:Organization
Organization Name:DANIELSVILLE FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MONROE
Authorized Official - Last Name:HAYMORE
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:706-795-5211
Mailing Address - Street 1:479 HIGHWAY 98 E
Mailing Address - Street 2:
Mailing Address - City:DANIELSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30633
Mailing Address - Country:US
Mailing Address - Phone:706-795-5211
Mailing Address - Fax:706-795-2519
Practice Address - Street 1:479 HIGHWAY 98 E
Practice Address - Street 2:
Practice Address - City:DANIELSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30633-5829
Practice Address - Country:US
Practice Address - Phone:706-795-5211
Practice Address - Fax:706-795-2519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA009721261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000755235AMedicaid
GA000755235AMedicaid
GA113888Medicare Oscar/Certification