Basic Information
| Provider Information | |||||||||
| NPI: | 1619977592 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRYOR | ||||||||
| FirstName: | EVELYN | ||||||||
| MiddleName: | BARANCO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2084 HEADLAND DRIVE | ||||||||
| Address2: | JENCARE NEIGHBORHOOD MEDICAL CENTER EAST POINT, LLC | ||||||||
| City: | EAST POINT | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303442135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4049655691 | ||||||||
| FaxNumber: | 4049655710 | ||||||||
| Practice Location | |||||||||
| Address1: | 2084 HEADLAND DRIVE | ||||||||
| Address2: | JENCARE NEIGHBORHOOD MEDICAL CENTER EAST POINT, LLC | ||||||||
| City: | EAST POINT | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303442135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4049655691 | ||||||||
| FaxNumber: | 4049655710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 08/19/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 053976 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 2006-01584 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 149934368B | 05 | GA | MEDICAID | P00378172 | 01 | NC | RAILROAD MEDICARE | OTHER | 5905358 | 05 | NC | MEDICAID | 1619977592 | 05 | NC | MEDICAID | Q0158H | 05 | SC | MEDICAID |