Provider Demographics
NPI:1417133893
Name:HILLANDALE PRIMARY CARE
Entity Type:Organization
Organization Name:HILLANDALE PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CLARICE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-322-9660
Mailing Address - Street 1:5900 HILLANDALE DR
Mailing Address - Street 2:SUITE 215
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-3802
Mailing Address - Country:US
Mailing Address - Phone:770-322-9660
Mailing Address - Fax:770-322-1981
Practice Address - Street 1:5900 HILLANDALE DR
Practice Address - Street 2:SUITE 215
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-3802
Practice Address - Country:US
Practice Address - Phone:770-322-9660
Practice Address - Fax:770-322-1981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039730207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4493Medicare PIN