Provider Demographics
NPI:1851300842
Name:HARALSON MEDICAL CLINIC, PC
Entity Type:Organization
Organization Name:HARALSON MEDICAL CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:IN
Authorized Official - Middle Name:SOOK
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-537-4818
Mailing Address - Street 1:201 ALLEN MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:GA
Mailing Address - Zip Code:30110
Mailing Address - Country:US
Mailing Address - Phone:770-537-4818
Mailing Address - Fax:770-537-6684
Practice Address - Street 1:201 ALLEN MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:GA
Practice Address - Zip Code:30110
Practice Address - Country:US
Practice Address - Phone:770-537-4818
Practice Address - Fax:770-537-6684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA16085207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300022742BMedicaid
GAGRP1938Medicare PIN