Provider Demographics
NPI:1982033411
Name:COMMONWEALTH PRIMARY CARE
Entity Type:Organization
Organization Name:COMMONWEALTH PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAYASRI
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLAVARAPU
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:678-455-2295
Mailing Address - Street 1:1614 PEACHTREE PKWY
Mailing Address - Street 2:SUITE # 200
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-6883
Mailing Address - Country:US
Mailing Address - Phone:678-455-2295
Mailing Address - Fax:678-455-2279
Practice Address - Street 1:1614 PEACHTREE PKWY
Practice Address - Street 2:SUITE # 200
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-6883
Practice Address - Country:US
Practice Address - Phone:678-455-2295
Practice Address - Fax:678-455-2279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-05
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA061288261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
511I080600Medicare Oscar/Certification
GA157049240BMedicaid