MEDICARE: PREMIER SOUTH MEDICAL GROUP, P.C.

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	207Q00000X	Family Medicine Physician	040754	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528114295
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER SOUTH MEDICAL GROUP, P.C.

Provider Business Mailing Address
First Line	:	8750 NW 36TH ST
Second Line	:	SUITE 300
City	:	DORAL
State	:	FL
Zip	:	33178-2425
Country	:	US
Telephone Number	:	786-641-5348
Fax Number	:	305-615-1121

Provider Business Practice Location Address
First Line	:	3885 PRINCETON LAKES WAY SW
Second Line	:	SUITE 412
City	:	ATLANTA
State	:	GA
Zip	:	30331-5589
Country	:	US
Telephone Number	:	404-344-6000
Fax Number	:	404-344-6575

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. EWAUL BARRINGTON PERSAUD JR.
Credential	:	M.D.
Telephone Number	:	404-344-6000

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	12/19/2016

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