Provider Demographics
NPI:1497955678
Name:MOUNTAIN PARK PRIMARY CARE CENTER
Entity Type:Organization
Organization Name:MOUNTAIN PARK PRIMARY CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:NOYD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-469-2040
Mailing Address - Street 1:1755 E PARK PLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3459
Mailing Address - Country:US
Mailing Address - Phone:770-469-2040
Mailing Address - Fax:770-469-7010
Practice Address - Street 1:1755 E PARK PLACE BLVD
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3459
Practice Address - Country:US
Practice Address - Phone:770-469-2040
Practice Address - Fax:770-469-7010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021187208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10036820OtherAMERIGROUP
GA00203761KMedicaid
GA10036820OtherAMERIGROUP
GA00203761KMedicaid