Healthcare Provider Details

I. General information

NPI: 1851300842
Provider Name (Legal Business Name): HARALSON MEDICAL CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 ALLEN MEMORIAL DR
BREMEN GA
30110
US

IV. Provider business mailing address

201 ALLEN MEMORIAL DR
BREMEN GA
30110
US

V. Phone/Fax

Practice location:
  • Phone: 770-537-4818
  • Fax: 770-537-6684
Mailing address:
  • Phone: 770-537-4818
  • Fax: 770-537-6684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16085
License Number StateGA

VIII. Authorized Official

Name: IN SOOK KIM
Title or Position: SECRETARY
Credential: MD
Phone: 770-537-4818