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General NPI Number Information
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NPI Number | 1275860900
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Entity Type | Organization
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Legal Business Name | OCONEE PRIMARY CARE, L.L.C.
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Dates
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Enumeration Date | 11/18/2009
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Last Update Date | 11/18/2009
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Provider Practice Location Address
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Address Line | 1624 MARS HILL RD SUITE B
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City | WATKINSVILLE
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State | GA
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Zip | 30677-4813
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Country | US
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Telephone | 404-759-6436
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Fax | 706-769-2750
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Provider Business Mailing Address
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Address Line | 1624 MARS HILL RD SUITE B
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City | WATKINSVILLE
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State | GA
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Zip | 30677-4813
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Country | US
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Telephone | 404-759-6436
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Fax | 706-769-2750
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | KEN H PARK
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Credential | MD
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Telephone | 404-759-6436
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 050049
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License Number State | GA
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