MEDICARE: PREMIER PRIMARY CARE CENTER, INC

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
1	208000000X	Pediatrics Physician	039888	GA
2	207R00000X	Internal Medicine Physician	039888	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	10033956	OTHER	GA	AMERIGROUP
3	52624568002	OTHER	GA	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1740311711
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER PRIMARY CARE CENTER, INC

Provider Business Mailing Address
First Line	:	5820 OLD NATIONAL HWY
Second Line	:	SUITE 250
City	:	COLLEGE PARK
State	:	GA
Zip	:	30349-3838
Country	:	US
Telephone Number	:	770-997-1565
Fax Number	:	770-997-1568

Provider Business Practice Location Address
First Line	:	5820 OLD NATIONAL HWY
Second Line	:
City	:	COLLEGE PARK
State	:	GA
Zip	:	30349-3838
Country	:	US
Telephone Number	:	770-997-1565
Fax Number	:	770-997-1568

Authorized Official
Title or Position	:	CEO
Name	:	DR. CHRISTAIN C. OHAGWU
Credential	:	M.D.
Telephone Number	:	404-766-1970

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	07/08/2016

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