Provider Demographics
NPI:1548445802
Name:PRIMARY CARE PHYSICIAN CENTER, PC
Entity type:Organization
Organization Name:PRIMARY CARE PHYSICIAN CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:404-252-1230
Mailing Address - Street 1:5197 ROSWELL RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-2213
Mailing Address - Country:US
Mailing Address - Phone:404-477-4712
Mailing Address - Fax:
Practice Address - Street 1:5197 ROSWELL RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-2213
Practice Address - Country:US
Practice Address - Phone:404-477-4712
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA23118261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4938Medicare UPIN