Provider Demographics
NPI:1376829028
Name:OLD NATIONAL PRIMARY CARE CLINIC, LLC
Entity Type:Organization
Organization Name:OLD NATIONAL PRIMARY CARE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EVA
Authorized Official - Middle Name:ISABELLE
Authorized Official - Last Name:BEAULIEU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-556-0495
Mailing Address - Street 1:1065 JODECO RD
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4953
Mailing Address - Country:US
Mailing Address - Phone:678-284-6300
Mailing Address - Fax:678-284-6336
Practice Address - Street 1:5185 OLD NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-3244
Practice Address - Country:US
Practice Address - Phone:404-763-9300
Practice Address - Fax:404-763-9306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-26
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA066254207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G709462Medicare PIN