Healthcare Provider Details

I. General information

NPI: 1205288164
Provider Name (Legal Business Name): MEDPRIME BROOKHAVEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2016
Last Update Date: 07/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 CONCOURSE PKWY SUITE 100
ATLANTA GA
30328-5371
US

IV. Provider business mailing address

1100 PEACHTREE ST NE SUITE 200
ATLANTA GA
30309-4501
US

V. Phone/Fax

Practice location:
  • Phone: 678-691-8239
  • Fax:
Mailing address:
  • Phone: 678-691-8239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number61430
License Number StateGA

VIII. Authorized Official

Name: SHERWIN EUGENE BRYANT
Title or Position: COMPLIANCE OFFICER
Credential: MHA
Phone: 678-691-8239