Provider Demographics
NPI:1689857195
Name:STATHAM FAMILY PRACTICE PC
Entity Type:Organization
Organization Name:STATHAM FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:DUROCHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-753-1122
Mailing Address - Street 1:1906 RAILROAD ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:STATHAM
Mailing Address - State:GA
Mailing Address - Zip Code:30666
Mailing Address - Country:US
Mailing Address - Phone:678-753-1122
Mailing Address - Fax:
Practice Address - Street 1:1906 RAILROAD ST
Practice Address - Street 2:SUITE C
Practice Address - City:STATHAM
Practice Address - State:GA
Practice Address - Zip Code:30666
Practice Address - Country:US
Practice Address - Phone:678-753-1122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056051207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH86387Medicare UPIN
GA511G700227Medicare PIN