MEDICARE: MEDPRIME BROOKHAVEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	305R00000X	Preferred Provider Organization	61430	GA

General Provider Information

NPI Number	:	1205288164
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDPRIME BROOKHAVEN

Provider Business Mailing Address
First Line	:	1100 PEACHTREE ST NE
Second Line	:	SUITE 200
City	:	ATLANTA
State	:	GA
Zip	:	30309-4501
Country	:	US
Telephone Number	:	678-691-8239
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 CONCOURSE PKWY
Second Line	:	SUITE 100
City	:	ATLANTA
State	:	GA
Zip	:	30328-5371
Country	:	US
Telephone Number	:	678-691-8239
Fax Number	:

Authorized Official
Title or Position	:	COMPLIANCE OFFICER
Name	:	SHERWIN EUGENE BRYANT
Credential	:	MHA
Telephone Number	:	678-691-8239

Provider Enumeration Date	:	07/04/2016
Last Update Date	:	07/04/2016

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Directions to “MEDPRIME BROOKHAVEN ” Practice Location

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