Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 12/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3885 PRINCETON LAKES WAY SW SUITE 412
ATLANTA GA
30331-5589
US

IV. Provider business mailing address

8750 NW 36TH ST SUITE 300
DORAL FL
33178-2425
US

V. Phone/Fax

Practice location:
  • Phone: 404-344-6000
  • Fax: 404-344-6575
Mailing address:
  • Phone: 786-641-5348
  • Fax: 305-615-1121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number040754
License Number StateGA

VIII. Authorized Official

Name: DR. EWAUL BARRINGTON PERSAUD JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 404-344-6000