Healthcare Provider Details

I. General information

NPI: 1326022328
Provider Name (Legal Business Name): HABERSHAM FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

865 AUSTIN DR
DEMOREST GA
30535-4513
US

IV. Provider business mailing address

PO BOX 308
DEMOREST GA
30535-0308
US

V. Phone/Fax

Practice location:
  • Phone: 706-754-8811
  • Fax: 706-754-8822
Mailing address:
  • Phone: 706-754-8811
  • Fax: 706-754-8822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number044718
License Number StateGA

VIII. Authorized Official

Name: DR. DONALD L FORDHAM
Title or Position: OWNER
Credential: M.D.
Phone: 706-754-8811