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NPI Code Detail

MEDICARE: OLD NATIONAL PRIMARY CARE CLINIC, LLC

MEDICARE: OLD NATIONAL PRIMARY CARE CLINIC, LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207R00000XInternal Medicine Physician066254GA

General Provider Information

NPI Number : 1376829028
Entity Type Code : Organization
Provider Name (Legal Business Name) : OLD NATIONAL PRIMARY CARE CLINIC, LLC
Provider Business Mailing Address
First Line : 1065 JODECO RD
Second Line :
City : STOCKBRIDGE
State : GA
Zip : 30281-4953
Country : US
Telephone Number : 678-284-6300
Fax Number : 678-284-6336
Provider Business Practice Location Address
First Line : 5185 OLD NATIONAL HWY
Second Line :
City : ATLANTA
State : GA
Zip : 30349-3244
Country : US
Telephone Number : 404-763-9300
Fax Number : 404-763-9306
Authorized Official
Title or Position : OWNER
Name : EVA ISABELLE BEAULIEU
Credential : M.D.
Telephone Number : 786-556-0495
Provider Enumeration Date : 10/26/2011
Last Update Date : 05/10/2013

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