Provider Demographics
NPI:1972056380
Name:ROMULUS PRIMARY CARE SERVICES
Entity Type:Organization
Organization Name:ROMULUS PRIMARY CARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAWNTREL
Authorized Official - Middle Name:
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-679-5812
Mailing Address - Street 1:675 CHESTATEE CREEK DR NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-3598
Mailing Address - Country:US
Mailing Address - Phone:678-977-6919
Mailing Address - Fax:
Practice Address - Street 1:4439 AUSTELL RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1839
Practice Address - Country:US
Practice Address - Phone:770-675-7407
Practice Address - Fax:770-693-5922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-02
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003145276CMedicaid