Provider Demographics
NPI:1346373180
Name:THE HOSPITAL AUTHORITY OF HABERSHAM COUNTY
Entity Type:Organization
Organization Name:THE HOSPITAL AUTHORITY OF HABERSHAM COUNTY
Other - Org Name:PRIMECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-754-3113
Mailing Address - Street 1:396 HISTORIC HIGHWAY 441 N
Mailing Address - Street 2:
Mailing Address - City:DEMOREST
Mailing Address - State:GA
Mailing Address - Zip Code:30535
Mailing Address - Country:US
Mailing Address - Phone:706-754-2273
Mailing Address - Fax:706-754-7300
Practice Address - Street 1:541 HISTORIC HWY 441 N
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-4528
Practice Address - Country:US
Practice Address - Phone:706-754-2273
Practice Address - Fax:706-754-7300
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE HOSPITAL AUTHORITY OF HABERSHAM COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-13
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4705360207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11D0944659OtherCLIA #
GA231OtherCOVENANT ADMINISTRATORS #
GA2466081OtherPHOENIX HOME LIFE
GA0930OtherHEALTHSTAR PROVIDER #
GADA0733OtherRAILROAD MCR PROVIDER #
GA2466081OtherPHOENIX HOME LIFE