Provider Demographics
NPI:1285963595
Name:PREMIER PSYCHIATRIC AND MEDICAL CONSULTANTS
Entity type:Organization
Organization Name:PREMIER PSYCHIATRIC AND MEDICAL CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:S
Authorized Official - Last Name:BOTNICK
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:404-403-3326
Mailing Address - Street 1:1430 STEPHENS DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-3716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1430 STEPHENS DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-3716
Practice Address - Country:US
Practice Address - Phone:404-403-3326
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-15
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN118785363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ22887Medicare UPIN