| Premier South Medical Group, P.c. | |
|
3885 Princeton Lakes Way Sw Suite 412 Atlanta GA 30331-5589 | |
| (404) 344-6000 | |
| (404) 344-6575 |
| Full Name | Premier South Medical Group, P.c. |
|---|---|
| Speciality | Family Medicine |
| Location | 3885 Princeton Lakes Way Sw, Atlanta, Georgia |
| Authorized Official Name and Position | Ewaul Barrington Persaud (PRESIDENT) |
| Authorized Official Contact | 4043446000 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Premier South Medical Group, P.c. 8750 Nw 36th St Suite 300 Doral FL 33178-2425 Ph: (786) 641-5348 | Premier South Medical Group, P.c. 3885 Princeton Lakes Way Sw Suite 412 Atlanta GA 30331-5589 Ph: (404) 344-6000 |
| NPI Number | 1528114295 |
|---|---|
| Provider Enumeration Date | 01/26/2007 |
| Last Update Date | 12/19/2016 |
| Medicare PECOS PAC ID | 4486940426 |
|---|---|
| Medicare Enrollment ID | O20160831000676 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1528114295 | NPI | - | NPPES |
| 00318272A | Medicaid | GA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | 040754 (Georgia) | Primary |
| Provider Name | Nakato Bonni Kibuyaga-travis |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1609031657 PECOS PAC ID: 5092982520 Enrollment ID: I20120124000229 |
| Provider Name | Joel T Isom |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1194930222 PECOS PAC ID: 3375788300 Enrollment ID: I20130322000369 |
| Provider Name | Natasha Williamson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1386033132 PECOS PAC ID: 1951689975 Enrollment ID: I20161026001660 |
| Provider Name | Audrey Caryn Roberson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1811495385 PECOS PAC ID: 9335549609 Enrollment ID: I20210609000563 |
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