Provider Demographics
NPI:1275860900
Name:OCONEE PRIMARY CARE, L.L.C.
Entity Type:Organization
Organization Name:OCONEE PRIMARY CARE, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:H
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-759-6436
Mailing Address - Street 1:1624 MARS HILL RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-4813
Mailing Address - Country:US
Mailing Address - Phone:404-759-6436
Mailing Address - Fax:706-769-2750
Practice Address - Street 1:1624 MARS HILL RD
Practice Address - Street 2:SUITE B
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-4813
Practice Address - Country:US
Practice Address - Phone:404-759-6436
Practice Address - Fax:706-769-2750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-18
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050049207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty