Provider Demographics
NPI:1194913053
Name:SOUTH METRO PRIMARY CARE
Entity type:Organization
Organization Name:SOUTH METRO PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN/OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOFTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-907-0070
Mailing Address - Street 1:261 MEDICAL WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2522
Mailing Address - Country:US
Mailing Address - Phone:770-907-0070
Mailing Address - Fax:770-996-5950
Practice Address - Street 1:261 MEDICAL WAY
Practice Address - Street 2:SUITE A
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2522
Practice Address - Country:US
Practice Address - Phone:770-907-0070
Practice Address - Fax:770-996-5950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GRP2917Medicare PIN