Provider Demographics
NPI:1063538924
Name:SOUTH DEKALB PRIMARY CARE, PC
Entity type:Organization
Organization Name:SOUTH DEKALB PRIMARY CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:WELCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-289-1952
Mailing Address - Street 1:1290 COLUMBIA DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-2824
Mailing Address - Country:US
Mailing Address - Phone:404-289-1952
Mailing Address - Fax:404-289-1953
Practice Address - Street 1:1290 COLUMBIA DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-2824
Practice Address - Country:US
Practice Address - Phone:404-289-1952
Practice Address - Fax:404-289-1953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA156445261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA156445OtherBUSINESS LICENSE