Provider Demographics
NPI:1598938185
Name:PRIMARY CARE GROUP OF WEST GEORGIA
Entity Type:Organization
Organization Name:PRIMARY CARE GROUP OF WEST GEORGIA
Other - Org Name:PULMONARY REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TREBBA
Authorized Official - Middle Name:
Authorized Official - Last Name:PUTNAM
Authorized Official - Suffix:
Authorized Official - Credentials:CPC MPA
Authorized Official - Phone:770-838-1570
Mailing Address - Street 1:100 PROFESSIONAL PL
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3874
Mailing Address - Country:US
Mailing Address - Phone:770-838-1570
Mailing Address - Fax:770-838-1722
Practice Address - Street 1:7869 VILLA RICA HWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-8638
Practice Address - Country:US
Practice Address - Phone:770-838-1570
Practice Address - Fax:770-838-1722
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIMARY CARE GROUP OF WEST GEORGIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2462Medicare PIN