MEDICARE: EVERGREEN PRIMARY CARE, PC

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	207R00000X	Internal Medicine Physician	051195	GA

General Provider Information

NPI Number	:	1821297920
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN PRIMARY CARE, PC

Provider Business Mailing Address
First Line	:	4855 RIVER GREEN PKWY
Second Line	:	SUITE 520
City	:	DULUTH
State	:	GA
Zip	:	30096-8336
Country	:	US
Telephone Number	:	678-417-1588
Fax Number	:	678-417-1589

Provider Business Practice Location Address
First Line	:	4855 RIVER GREEN PKWY
Second Line	:	SUITE 520
City	:	DULUTH
State	:	GA
Zip	:	30096-8336
Country	:	US
Telephone Number	:	678-417-1588
Fax Number	:	678-417-1589

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ALICE-WEI YOU
Credential	:	M.D.
Telephone Number	:	678-417-1588

Provider Enumeration Date	:	07/17/2007
Last Update Date	:	07/17/2007

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