Provider Demographics
NPI:1831537539
Name:PROVIDENCE RD PRIMARY CARE LLC
Entity type:Organization
Organization Name:PROVIDENCE RD PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:AMMA
Authorized Official - Middle Name:
Authorized Official - Last Name:ABUNYEWA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-973-4749
Mailing Address - Street 1:4180 PROVIDENCE RD
Mailing Address - Street 2:STE 105
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-6186
Mailing Address - Country:US
Mailing Address - Phone:770-973-4749
Mailing Address - Fax:770-973-4349
Practice Address - Street 1:4180 PROVIDENCE RD
Practice Address - Street 2:STE 105
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-6186
Practice Address - Country:US
Practice Address - Phone:770-973-4749
Practice Address - Fax:770-973-4349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA64774207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty