Provider Demographics
NPI:1922104306
Name:PARK CENTRAL FAMILY PRACTICE, INC.
Entity Type:Organization
Organization Name:PARK CENTRAL FAMILY PRACTICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERRIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-981-2008
Mailing Address - Street 1:4367 NEW SNAPFINGER WOODS DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30035-2920
Mailing Address - Country:US
Mailing Address - Phone:770-981-2008
Mailing Address - Fax:770-981-6302
Practice Address - Street 1:4367 NEW SNAPFINGER WOODS DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-2920
Practice Address - Country:US
Practice Address - Phone:770-981-2008
Practice Address - Fax:770-981-6302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA172813090AMedicaid
GA172813090AMedicaid