Provider Demographics
NPI:1386676211
Name:PRINCE AVENUE PRIMARY CARE, L.L.C.
Entity Type:Organization
Organization Name:PRINCE AVENUE PRIMARY CARE, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:B
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-227-2027
Mailing Address - Street 1:892 PRINCE AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2724
Mailing Address - Country:US
Mailing Address - Phone:706-227-2027
Mailing Address - Fax:706-227-2433
Practice Address - Street 1:892 PRINCE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2724
Practice Address - Country:US
Practice Address - Phone:706-227-2027
Practice Address - Fax:706-227-2433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA015584207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3169Medicare ID - Type UnspecifiedGROUP NUMBER