Provider Demographics
NPI:1023835782
Name:EPITOME PRIMARY CARE
Entity type:Organization
Organization Name:EPITOME PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:ST-GOURDIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-695-6080
Mailing Address - Street 1:631 CAMPBELL HILL ST NW STE 200
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1390
Mailing Address - Country:US
Mailing Address - Phone:770-727-6124
Mailing Address - Fax:
Practice Address - Street 1:631 CAMPBELL HILL ST NW STE 200
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1390
Practice Address - Country:US
Practice Address - Phone:770-727-6124
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-24
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty