Provider Demographics
NPI:1528114295
Name:PREMIER SOUTH MEDICAL GROUP, P.C.
Entity type:Organization
Organization Name:PREMIER SOUTH MEDICAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EWAUL
Authorized Official - Middle Name:BARRINGTON
Authorized Official - Last Name:PERSAUD
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:404-344-6000
Mailing Address - Street 1:8750 NW 36TH ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-2425
Mailing Address - Country:US
Mailing Address - Phone:786-641-5348
Mailing Address - Fax:305-615-1121
Practice Address - Street 1:3885 PRINCETON LAKES WAY SW
Practice Address - Street 2:SUITE 412
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-5589
Practice Address - Country:US
Practice Address - Phone:404-344-6000
Practice Address - Fax:404-344-6575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040754207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00318272AMedicaid
GA202G704025Medicare UPIN