Provider Demographics
NPI:1710183454
Name:SOUTH ATLANTA PRIMARY CARE PC
Entity Type:Organization
Organization Name:SOUTH ATLANTA PRIMARY CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANGEL
Authorized Official - Last Name:DICRISTINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-968-7933
Mailing Address - Street 1:6568A TARA BLVD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-1228
Mailing Address - Country:US
Mailing Address - Phone:770-968-7933
Mailing Address - Fax:770-968-6521
Practice Address - Street 1:6568A TARA BLVD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1228
Practice Address - Country:US
Practice Address - Phone:770-968-7933
Practice Address - Fax:770-968-6521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022223173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1144226135OtherIND NPI NUMBER
GAD29297Medicare UPIN
GA1144226135OtherIND NPI NUMBER