Provider Demographics
NPI:1447385158
Name:HARBIN CLINIC, LLC
Entity Type:Organization
Organization Name:HARBIN CLINIC, LLC
Other - Org Name:HARBIN GI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DIEHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:762-235-1166
Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:1825 MARTHA BERRY BLVD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1625
Practice Address - Country:US
Practice Address - Phone:706-295-5331
Practice Address - Fax:706-238-8011
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HARBIN CLINIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-22
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057-251261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000823413AMedicaid