Provider Demographics
NPI:1841800679
Name:OM PRIMARY CARE LLC
Entity Type:Organization
Organization Name:OM PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KINJAL
Authorized Official - Middle Name:AMIT
Authorized Official - Last Name:KACHALIA
Authorized Official - Suffix:
Authorized Official - Credentials:MBBS MBA
Authorized Official - Phone:470-416-3424
Mailing Address - Street 1:220 NEWPORT FAIRWAY
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-7825
Mailing Address - Country:US
Mailing Address - Phone:470-416-3424
Mailing Address - Fax:
Practice Address - Street 1:4300 WESTBROOK RD BLDG A
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4987
Practice Address - Country:US
Practice Address - Phone:470-416-3424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty