Provider Demographics
NPI:1801078001
Name:HAZIM A. FARISI MD PC
Entity type:Organization
Organization Name:HAZIM A. FARISI MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:FARISI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-714-5692
Mailing Address - Street 1:4965 FRIENDSHIP RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-1700
Mailing Address - Country:US
Mailing Address - Phone:678-714-5692
Mailing Address - Fax:678-714-5693
Practice Address - Street 1:4965 FRIENDSHIP RD
Practice Address - Street 2:SUITE 103
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-1700
Practice Address - Country:US
Practice Address - Phone:678-714-5692
Practice Address - Fax:678-714-5693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016201208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1700938123OtherINDIVIDUAL NPI
GA00457168CMedicaid
GAGRP4668OtherGROUP PIN
GA1801078001OtherGROUP NPI
GAGRP4668OtherGROUP PIN
GAD09720Medicare UPIN