Provider Demographics
NPI:1104033315
Name:SNELLVILLE PRIMARY CARE
Entity Type:Organization
Organization Name:SNELLVILLE PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR - OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:GHAYOURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-979-1544
Mailing Address - Street 1:1800 TREE LN
Mailing Address - Street 2:STE 290A
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2016
Mailing Address - Country:US
Mailing Address - Phone:770-979-1544
Mailing Address - Fax:770-979-5662
Practice Address - Street 1:1800 TREE LN
Practice Address - Street 2:STE 290A
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2016
Practice Address - Country:US
Practice Address - Phone:770-979-1544
Practice Address - Fax:770-979-5662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017573207Q00000X
GA039109207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00623389AMedicaid
GAGRP2331Medicare ID - Type Unspecified