Provider Demographics
NPI:1659494847
Name:PREMIER INTERNAL MEDICINE
Entity Type:Organization
Organization Name:PREMIER INTERNAL MEDICINE
Other - Org Name:RICHARD J. BRECKWOLDT,M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRECKWOLDT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-384-0800
Mailing Address - Street 1:5604 WENDYBAGWELL PKWY (HWY 278)
Mailing Address - Street 2:SUITE 711
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-2291
Mailing Address - Country:US
Mailing Address - Phone:678-384-0800
Mailing Address - Fax:678-384-0801
Practice Address - Street 1:5604 WENDY BAGWELL PKWY
Practice Address - Street 2:STE 711
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-7813
Practice Address - Country:US
Practice Address - Phone:678-384-0800
Practice Address - Fax:678-384-0801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039295207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000656103BMedicaid
GA000656103BMedicaid