NPIMap

Organization Active NPI

Four Corners Primary Care Centers Inc

  • Federally Qualified Health Center (FQHC)
  • Norcross, GA
National Provider Identifier
1265624548
Registry record updated Sep 1, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
FOUR CORNERS PRIMARY CARE CENTERS INC
Practice address
5300 Oakbrook Pkwy
Suite 130
Norcross, GA 30093-2256
Phone
(770) 279-3142
Fax
(770) 234-5210
NPI assigned
Aug 10, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 1, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Brian O. Williams, M.D.
Title
Ceo
Phone
(770) 279-3140

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

5300 Oakbrook Pkwy
Suite 130
Norcross, GA 30093-2256

Mailing address

5300 Oakbrook Pkwy
Suite 130
Norcross, GA 30093-2256
Phone (770) 279-3142

Other identifiers 1

IdentifierTypeStateIssuer
162765396AMedicaidGA

Other names 1

  • Four Corners @ VPH Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20071015000519 GA Part A Provider - Federally Qualified Health Center (FQHC) 1951497494 Practice locations: Norcross, GA
O20080117000193 GA Part B Supplier - Clinic/Group Practice 1951497494 Receives reassigned benefits from 17 practitioners
Practice locations: Norcross, GA

Federally qualified health center certification: CCN 111901

Legal name
FOUR CORNERS PRIMARY CARE CENTERS, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 14, 2007
Last certification
Nov 14, 2007
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 6, 2007 in GA
Enrollment address
5300 Oakbrook Pkwy
Ste 130
Norcross, GA 30093-2261

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory

Locations

318 W Pike St
Ste 100
Lawrenceville, GA 30046
Phone (770) 806-2928

5300 Oakbrook Pkwy
Ste 130
Norcross, GA 30093
Phone (770) 279-3176

Ownership & related parties

All disclosed owners & managing parties 13

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Angel G Amaro Individual Corporate DirectorBoard Member Feb 6, 2014
William G Mayfield Individual Corporate DirectorBoard Member Jul 17, 2013
Walter Murray Individual Corporate OfficerCfo Jul 1, 2014
Vanessa M Robinson-Dooley Individual Corporate DirectorBoard Member Feb 15, 2011
Brian O Williams Individual Corporate OfficerCeo Jan 1, 2012
Operational/Managerial Control Jan 1, 2012
Rossana Mangual Individual Corporate DirectorBoard Member Feb 6, 2014
Mary Jane Labonte Individual Corporate DirectorBoard Member Sep 16, 2008
Angela F Watkins Individual Corporate DirectorBoard Member Jan 24, 2014
Eric L Banum Individual Corporate DirectorBoard Member Feb 6, 2014
Jeanine B Oliga Individual Corporate DirectorMedical Director Mar 24, 2014
Julie a Crosby- San Miguel Individual Corporate DirectorBoard Member May 8, 2010
Cappel Sookdeu Individual Corporate DirectorBoard Member Feb 6, 2014
Lily Arfa Morehouse Individual Corporate DirectorBoard Member Mar 18, 2014

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 18

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 18

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1186704000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1472688000000",
    "number": "1265624548",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5300 OAKBROOK PKWY",
            "address_2": "SUITE 130",
            "city": "NORCROSS",
            "state": "GA",
            "postal_code": "300932256",
            "telephone_number": "770-279-3142",
            "fax_number": "770-234-5210"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5300 OAKBROOK PKWY",
            "address_2": "SUITE 130",
            "city": "NORCROSS",
            "state": "GA",
            "postal_code": "300932256",
            "telephone_number": "770-279-3142",
            "fax_number": "770-234-5210"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FOUR CORNERS PRIMARY CARE CENTERS INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-08-10",
        "last_updated": "2016-09-01",
        "status": "A",
        "authorized_official_last_name": "WILLIAMS",
        "authorized_official_first_name": "BRIAN",
        "authorized_official_middle_name": "O.",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "770-279-3140",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "162765396A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Four Corners @ VPH",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Norcross, GA

Sources for this page

Verify at the official NPI Registry.