Provider Demographics
NPI:1376600825
Name:PREMIER MEDICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:PREMIER MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUKOSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-888-6697
Mailing Address - Street 1:407 E MAPLE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2635
Mailing Address - Country:US
Mailing Address - Phone:770-888-6697
Mailing Address - Fax:770-888-6698
Practice Address - Street 1:407 E MAPLE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2656
Practice Address - Country:US
Practice Address - Phone:770-888-6697
Practice Address - Fax:770-888-6698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054743207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6994Medicare ID - Type Unspecified