Provider Demographics
NPI:1235167982
Name:REDAN HAIRSTON FAMILY MEDICINE
Entity Type:Organization
Organization Name:REDAN HAIRSTON FAMILY MEDICINE
Other - Org Name:REDAN HAIRSTON PEDIATRIC & ADULT MEDICINE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMMACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-297-1818
Mailing Address - Street 1:8225 MALL PKWY
Mailing Address - Street 2:SUITE 250
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-6994
Mailing Address - Country:US
Mailing Address - Phone:404-297-1818
Mailing Address - Fax:404-297-1629
Practice Address - Street 1:8225 MALL PKWY
Practice Address - Street 2:SUITE 250
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-6994
Practice Address - Country:US
Practice Address - Phone:404-297-1818
Practice Address - Fax:404-297-1629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTAX ID