Provider Demographics
NPI:1952351116
Name:MASON PRIMARY CARE CLINIC, LP
Entity Type:Organization
Organization Name:MASON PRIMARY CARE CLINIC, LP
Other - Org Name:MASON PRIMARY CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MISSY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-622-3114
Mailing Address - Street 1:PO BOX 248
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-0005
Mailing Address - Country:US
Mailing Address - Phone:770-476-3636
Mailing Address - Fax:770-476-5845
Practice Address - Street 1:3500 MCCLURE BRIDGE RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-3131
Practice Address - Country:US
Practice Address - Phone:770-476-3636
Practice Address - Fax:770-476-5845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000364339SMedicaid
GA000817363DMedicaid
GA055002346AMedicaid
GAGRP2098Medicare ID - Type UnspecifiedMPC
GA11SCCTCMedicare ID - Type UnspecifiedDR ZHONG
GA000817363DMedicaid
GAG87527Medicare UPIN
GA055002346AMedicaid