Provider Demographics
NPI:1427337021
Name:MOUNT VERNON PREMIER CARE, LLC
Entity type:Organization
Organization Name:MOUNT VERNON PREMIER CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLADSTONE
Authorized Official - Middle Name:ARNOLD
Authorized Official - Last Name:SELLERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-419-9970
Mailing Address - Street 1:755 MOUNT VERNON HWY NE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4274
Mailing Address - Country:US
Mailing Address - Phone:404-419-9970
Mailing Address - Fax:404-252-8930
Practice Address - Street 1:755 MOUNT VERNON HWY NE
Practice Address - Street 2:SUITE 400
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4274
Practice Address - Country:US
Practice Address - Phone:404-419-9970
Practice Address - Fax:404-252-8930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA35513207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD92816Medicare UPIN
GAD39772Medicare UPIN