Provider Demographics
NPI:1093717357
Name:FAMILY PRACTICE OF HABERSHAM PC
Entity Type:Organization
Organization Name:FAMILY PRACTICE OF HABERSHAM PC
Other - Org Name:HABERSHAM PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:706-754-5511
Mailing Address - Street 1:PO BOX 1779
Mailing Address - Street 2:590 HISTORIC HWY 441 N.
Mailing Address - City:DEMOREST
Mailing Address - State:GA
Mailing Address - Zip Code:30535-1779
Mailing Address - Country:US
Mailing Address - Phone:706-754-5511
Mailing Address - Fax:706-754-5577
Practice Address - Street 1:590 HISTORIC HWY 441 N
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535
Practice Address - Country:US
Practice Address - Phone:706-754-5511
Practice Address - Fax:706-754-5577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032741207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACI7226Medicare ID - Type UnspecifiedRAILROAD MEDICARE NUMBER
GAGRP3078Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER