Provider Demographics
NPI:1669916573
Name:PREMIER SOUTH MEDICAL GROUP PC
Entity type:Organization
Organization Name:PREMIER SOUTH MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:REANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMKHELAWAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-281-2398
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 1:770 GREISON TRL
Practice Address - Street 2:SUITE F
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-6408
Practice Address - Country:US
Practice Address - Phone:770-251-4120
Practice Address - Fax:770-251-4575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-12
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003182726AMedicaid
GA202G704025Medicare UPIN