Healthcare Provider Details

I. General information

NPI: 1164940672
Provider Name (Legal Business Name): PRIMECARE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 UPPER RIVERDALE RD SW STE 201
RIVERDALE GA
30274-2614
US

IV. Provider business mailing address

86 UPPER RIVERDALE RD SW STE 201
RIVERDALE GA
30274-2614
US

V. Phone/Fax

Practice location:
  • Phone: 770-907-4219
  • Fax:
Mailing address:
  • Phone: 770-907-4219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MISS BRIDGETTE HANNIGAN
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 678-755-5334