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General NPI Number Information
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NPI Number | 1740506427
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Entity Type | Organization
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Legal Business Name | PERSONALIZED PRIMARY CARE OF ATLANTA LLC
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Dates
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Enumeration Date | 04/20/2010
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Last Update Date | 11/01/2022
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Provider Practice Location Address
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Address Line | 57 EXECUTIVE PARK S STE 390
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City | ATLANTA
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State | GA
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Zip | 30329-2288
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Country | US
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Telephone | 404-371-1033
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Fax | 404-997-6790
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Provider Business Mailing Address
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Address Line | 57 EXECUTIVE PARK S STE 390
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City | ATLANTA
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State | GA
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Zip | 30329-2255
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Country | US
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Telephone | 404-997-6790
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Fax | 404-997-6791
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | DR. JULIET K. MAVROMATIS
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Credential | MD
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Telephone | 404-583-0978
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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 | 043699
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License Number State | GA
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