Provider Demographics
NPI:1437428331
Name:PEACHTREE PRIMARY CARE PC
Entity Type:Organization
Organization Name:PEACHTREE PRIMARY CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANILA
Authorized Official - Middle Name:H
Authorized Official - Last Name:QIDWAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-676-6838
Mailing Address - Street 1:1570 OLD ALABAMA RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-2107
Mailing Address - Country:US
Mailing Address - Phone:770-676-6838
Mailing Address - Fax:770-676-6840
Practice Address - Street 1:1570 OLD ALABAMA RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-2107
Practice Address - Country:US
Practice Address - Phone:770-676-6838
Practice Address - Fax:770-676-6840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-21
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA065787207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty