Provider Demographics
NPI:1174851919
Name:SOUTH FULTON PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:SOUTH FULTON PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP CLIENT OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:LOGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-252-2137
Mailing Address - Street 1:2220 WISTERIA DR
Mailing Address - Street 2:SUITE 208
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2656
Mailing Address - Country:US
Mailing Address - Phone:678-252-2137
Mailing Address - Fax:678-336-7099
Practice Address - Street 1:1203 CLEVELAND AVE
Practice Address - Street 2:SUITE 1A
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3417
Practice Address - Country:US
Practice Address - Phone:404-305-8900
Practice Address - Fax:404-305-8099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-04
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046202207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty