Basic Information
| Provider Information | |||||||||
| NPI: | 1356472914 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIER IMMEDIATE CARE OF GEORGIA, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PREMIER IMMEDIATE CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8581 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049158581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783761300 | ||||||||
| FaxNumber: | 6784071469 | ||||||||
| Practice Location | |||||||||
| Address1: | 289 GRAYSON HWY | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300465726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783761300 | ||||||||
| FaxNumber: | 6784071469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 09/24/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HENDERSON | ||||||||
| AuthorizedOfficialFirstName: | PHILIP | ||||||||
| AuthorizedOfficialMiddleName: | NORTON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6783761300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MD, MPH, MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | 047601 | GA | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 261QX0100X | 047601 | GA | N | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine | 261QP2300X | 047601 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.