Healthcare Provider Details

I. General information

NPI: 1689857195
Provider Name (Legal Business Name): STATHAM FAMILY PRACTICE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2007
Last Update Date: 02/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 RAILROAD ST SUITE C
STATHAM GA
30666
US

IV. Provider business mailing address

1906 RAILROAD ST SUITE C
STATHAM GA
30666
US

V. Phone/Fax

Practice location:
  • Phone: 678-753-1122
  • Fax:
Mailing address:
  • Phone: 678-753-1122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number056051
License Number StateGA

VIII. Authorized Official

Name: DR. STEVEN A DUROCHER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 678-753-1122