Provider Demographics
NPI:1255741807
Name:ATHENS FAMILY MEDICINE
Entity type:Organization
Organization Name:ATHENS FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-548-1555
Mailing Address - Street 1:2205 BARNETT SHOALS RD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30605-3605
Mailing Address - Country:US
Mailing Address - Phone:706-548-1555
Mailing Address - Fax:706-548-1577
Practice Address - Street 1:2205 BARNETT SHOALS RD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30605-3605
Practice Address - Country:US
Practice Address - Phone:706-548-1555
Practice Address - Fax:706-548-1577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-05
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026381207Q00000X
GA031605207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1255741807OtherGROUP NPI
GA1255741807OtherGROUP NPI