Provider Demographics
NPI:1962678524
Name:HABERSHAM INTERNAL MEDICINE
Entity Type:Organization
Organization Name:HABERSHAM INTERNAL MEDICINE
Other - Org Name:HABERSHAM INTERNAL MEDICINE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-754-8066
Mailing Address - Street 1:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:DEMOREST
Mailing Address - State:GA
Mailing Address - Zip Code:30535
Mailing Address - Country:US
Mailing Address - Phone:706-754-8066
Mailing Address - Fax:706-754-8086
Practice Address - Street 1:870 AUSTIN DRIVE
Practice Address - Street 2:SUITE C
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535
Practice Address - Country:US
Practice Address - Phone:706-754-8066
Practice Address - Fax:706-754-8086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026464174400000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP144OtherMEDICARE GROUP NUMBER
GA000406062AMedicaid
D44914Medicare UPIN
GAGRP144OtherMEDICARE GROUP NUMBER