Basic Information
| Provider Information | |||||||||
| NPI: | 1245746783 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PIEDMONT ATHENS PRIMARY CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 117264 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303687264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708012500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1199 PRINCE AVE | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306062797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063695440 | ||||||||
| FaxNumber: | 7063695490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2017 | ||||||||
| LastUpdateDate: | 08/11/2021 | ||||||||
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| AuthorizedOfficialLastName: | AQUINO | ||||||||
| AuthorizedOfficialFirstName: | CHRISTY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 4702713427 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 08/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 003208591A | 05 | GA | MEDICAID |