Provider Demographics
NPI:1083819429
Name:PREMIER WOMENS OBGYN, LLC
Entity type:Organization
Organization Name:PREMIER WOMENS OBGYN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGEMENT CONSULTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-716-6203
Mailing Address - Street 1:237 UPPER RIVERDALE RD SW
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2537
Mailing Address - Country:US
Mailing Address - Phone:770-909-5003
Mailing Address - Fax:770-909-5004
Practice Address - Street 1:237 UPPER RIVERDALE RD SW
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2537
Practice Address - Country:US
Practice Address - Phone:770-909-5003
Practice Address - Fax:770-909-5004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-17
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054127207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA547811054AMedicaid
GA547811054AMedicaid