MEDICARE: CAMP CREEK 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	207Q00000X	Family Medicine Physician	043019	GA

General Provider Information

NPI Number	:	1861503906
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMP CREEK PRIMARY CARE, PC

Provider Business Mailing Address
First Line	:	PO BOX 90237
Second Line	:
City	:	EAST POINT
State	:	GA
Zip	:	30364-0237
Country	:	US
Telephone Number	:	404-349-2273
Fax Number	:	404-349-1511

Provider Business Practice Location Address
First Line	:	3890 REDWINE RD SW
Second Line	:	SUITE 100
City	:	ATLANTA
State	:	GA
Zip	:	30331-5509
Country	:	US
Telephone Number	:	404-349-2273
Fax Number	:	404-349-1511

Authorized Official
Title or Position	:	CFO/ BUSINESS MANAGER
Name	:	MS. LISA B. GREEN-CLOPTON
Credential	:	JD
Telephone Number	:	404-349-2273

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	08/22/2020

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