Provider Demographics
NPI:1598168650
Name:SMYRNA FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:SMYRNA FAMILY MEDICINE, LLC
Other - Org Name:PREMIER PRIMARY CARE MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:N
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-292-0043
Mailing Address - Street 1:4480 SOUTH COBB DR
Mailing Address - Street 2:BLDG H, STE 399
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080
Mailing Address - Country:US
Mailing Address - Phone:770-292-0043
Mailing Address - Fax:888-556-8420
Practice Address - Street 1:3903 S COBB DR SE STE 200
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6301
Practice Address - Country:US
Practice Address - Phone:770-292-0043
Practice Address - Fax:888-556-8420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-03
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA050306207Q00000X
GA000489363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00922864AMedicaid
GA08BBVXJMedicare UPIN
GA00922864AMedicaid