Healthcare Provider Details

I. General information

NPI: 1881084879
Provider Name (Legal Business Name): PRIMARY CARE AT CHILDRENS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2015
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 NORTHEAST EXPY NE
BROOKHAVEN GA
30329-2401
US

IV. Provider business mailing address

1575 NORTHEAST EXPY NE
BROOKHAVEN GA
30329-2401
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-5437
  • Fax:
Mailing address:
  • Phone: 404-785-7928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: RUTH FOWLER
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 404-785-5437