Provider Demographics
NPI:1356472914
Name:PREMIER IMMEDIATE CARE OF GEORGIA, PC
Entity type:Organization
Organization Name:PREMIER IMMEDIATE CARE OF GEORGIA, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:NORTON
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH, MBA
Authorized Official - Phone:678-376-1300
Mailing Address - Street 1:PO BOX 8581
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-8581
Mailing Address - Country:US
Mailing Address - Phone:678-376-1300
Mailing Address - Fax:678-407-1469
Practice Address - Street 1:289 GRAYSON HWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-5726
Practice Address - Country:US
Practice Address - Phone:678-376-1300
Practice Address - Fax:678-407-1469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047601261QU0200X, 261QX0100X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1316963358Medicare Oscar/Certification
GA6380470001Medicare NSC
GA08BBVBLMedicare PIN
GA1356472914Medicare Oscar/Certification
1356472914Medicare Oscar/Certification