Provider Demographics
NPI:1528113107
Name:PREMIER FAMILY CLINIC
Entity type:Organization
Organization Name:PREMIER FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NIPUN
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-493-6767
Mailing Address - Street 1:3646 CHAMBLEE TUCKER RD STE D
Mailing Address - Street 2:
Mailing Address - City:CHAMBLEE
Mailing Address - State:GA
Mailing Address - Zip Code:30341-4406
Mailing Address - Country:US
Mailing Address - Phone:770-493-6767
Mailing Address - Fax:770-493-6797
Practice Address - Street 1:3646 CHAMBLEE TUCKER RD STE B
Practice Address - Street 2:
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341-4406
Practice Address - Country:US
Practice Address - Phone:770-493-6767
Practice Address - Fax:770-493-6797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA46800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000821917FMedicaid
GAGRP5094Medicare ID - Type UnspecifiedGROUP ID