Provider Demographics
NPI:1083622849
Name:ALPHA INTERNAL MEDICINE, LLC
Entity Type:Organization
Organization Name:ALPHA INTERNAL MEDICINE, LLC
Other - Org Name:ALPHA INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:S
Authorized Official - Last Name:HORTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-719-5490
Mailing Address - Street 1:PO BOX 142459
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-6515
Mailing Address - Country:US
Mailing Address - Phone:770-719-5490
Mailing Address - Fax:770-719-3113
Practice Address - Street 1:745 GLYNN ST S
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-2049
Practice Address - Country:US
Practice Address - Phone:770-719-5490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA720353133V00000X
GA040693207R00000X
GA055270207R00000X
GA053123207R00000X
GA047760207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00753519BMedicaid
GA510368765AMedicaid
GAGRP4628Medicare ID - Type Unspecified
GA11BDNBZMedicare ID - Type Unspecified
GA00753519BMedicaid
GAI13217Medicare UPIN
GA11SCCXJMedicare ID - Type Unspecified