Provider Demographics
NPI:1144548363
Name:SOUTH ATLANTA URGENT CARE CLINIC LLC
Entity type:Organization
Organization Name:SOUTH ATLANTA URGENT CARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FELIX
Authorized Official - Middle Name:
Authorized Official - Last Name:AMOA-BONSU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-903-8830
Mailing Address - Street 1:5185 OLD NATIONAL HWY
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-3244
Mailing Address - Country:US
Mailing Address - Phone:404-763-9300
Mailing Address - Fax:404-763-9306
Practice Address - Street 1:5185 OLD NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-3244
Practice Address - Country:US
Practice Address - Phone:404-763-9300
Practice Address - Fax:404-763-9304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-12
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055916261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003114111AMedicaid
GA202G937460Medicare PIN