Provider Demographics
NPI:1033389564
Name:PRIMARY CARE SPECIALISTS
Entity Type:Organization
Organization Name:PRIMARY CARE SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GENISE
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-705-2355
Mailing Address - Street 1:315 BOULEVARD NE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312
Mailing Address - Country:US
Mailing Address - Phone:678-705-2355
Mailing Address - Fax:678-705-2378
Practice Address - Street 1:315 BOULEVARD NE
Practice Address - Street 2:SUITE 310
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312
Practice Address - Country:US
Practice Address - Phone:678-705-2355
Practice Address - Fax:678-705-2378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050559207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000930234BMedicaid
GAH50406Medicare UPIN
GA000930234BMedicaid