NPIMap

Organization Active NPI

Four Corners Primary Care Centers, Inc.

  • Federally Qualified Health Center (FQHC)
  • Lawrenceville, GA
National Provider Identifier
1285325282
Registry record updated May 19, 2023
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
318 W Pike St Ste 100
Lawrenceville, GA 30046-3234
Phone
(770) 806-2928
NPI assigned
May 19, 2023
Organization subpart
Yes
Parent organization
FOUR CORNERS PRIMARY CARE CENTERS, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on May 19, 2023

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

Authorized official

Name
Brian Oneal Williams, MD
Title
Ceo
Phone
(770) 279-3141

Specialties & licenses 1

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

Addresses

Primary practice location

318 W Pike St Ste 100
Lawrenceville, GA 30046-3234

Mailing address

5300 Oakbrook Pkwy Ste 130
Norcross, GA 30093-2261
Phone (770) 279-3176

Other names 1

  • Four Corners Primary Care Centers, W Pike Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20240912003032 GA Part A Provider - Federally Qualified Health Center (FQHC) 1951497494 Practice locations: Lawrenceville, GA

Federally qualified health center certification: CCN C21021

Legal name
FOUR CORNERS PRIMARY CARE CENTERS, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 12, 2024
Last certification
Sep 12, 2024
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 6, 2007 in GA
Enrollment address
318 W Pike St
Ste 100
Lawrenceville, GA 30046-3234

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
Tax ID family
Four Corners Prim Care4 organizations share this tax ID, including this one
Part of
Four Corners Prim Care

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Locations

115 Towne Center Pkwy
Ste 113
Hoschton, GA 30548
Phone (706) 658-2452

Ownership & related parties

All disclosed owners & managing parties 7

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

NameRoleSinceShare
Vanessa M Robinson-Dooley Individual Corporate OfficerBoard Chair Mar 1, 2016 100%
Brian O Williams Individual 5% Or Greater Direct Ownership InterestCeo Mar 1, 2016 100%
Corporate OfficerCeo Mar 1, 2016 100%
W-2 Managing EmployeeAd; Mar 1, 2016
Ruchi Bhavsar Individual W-2 Managing EmployeeMD; Nov 1, 2021 100%
Antonio Quinones Individual Corporate OfficerOfficer May 1, 2022 100%
Julie a Crosby- San Miguel Individual Corporate OfficerOfficer Mar 1, 2016 100%
Veronica Palomino Individual W-2 Managing EmployeeAd; Aug 16, 2011 100%
Michael Bekele Individual W-2 Managing EmployeeAd; Mar 1, 2024 100%

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 20

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

View all 20

NPI Registry JSON

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

{
    "created_epoch": "1684454400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1684454400000",
    "number": "1285325282",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5300 OAKBROOK PKWY STE 130",
            "city": "NORCROSS",
            "state": "GA",
            "postal_code": "300932261",
            "telephone_number": "770-279-3176"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "318 W PIKE ST STE 100",
            "city": "LAWRENCEVILLE",
            "state": "GA",
            "postal_code": "300463234",
            "telephone_number": "770-806-2928"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FOUR CORNERS PRIMARY CARE CENTERS, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "FOUR CORNERS PRIMARY CARE CENTERS, INC.",
        "enumeration_date": "2023-05-19",
        "last_updated": "2023-05-19",
        "certification_date": "2023-05-09",
        "status": "A",
        "authorized_official_last_name": "WILLIAMS",
        "authorized_official_first_name": "BRIAN",
        "authorized_official_middle_name": "ONEAL",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "770-279-3141",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Four Corners Primary Care Centers, W Pike",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Lawrenceville, GA

Sources for this page

Verify at the official NPI Registry.