Provider Demographics
NPI:1740311711
Name:PREMIER PRIMARY CARE CENTER, INC
Entity type:Organization
Organization Name:PREMIER PRIMARY CARE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTAIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:OHAGWU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-766-1970
Mailing Address - Street 1:5820 OLD NATIONAL HWY
Mailing Address - Street 2:SUITE 250
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-3838
Mailing Address - Country:US
Mailing Address - Phone:770-997-1565
Mailing Address - Fax:770-997-1568
Practice Address - Street 1:5820 OLD NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-3838
Practice Address - Country:US
Practice Address - Phone:770-997-1565
Practice Address - Fax:770-997-1568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039888207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300033306AMedicaid
GA10033956OtherAMERIGROUP
GA52624568002OtherBLUE CROSS BLUE SHIELD
GA121472Medicare ID - Type Unspecified