Four Corners Primary Care Centers Inc
Organization Active NPI Federally Qualified Health Center (FQHC) · Hoschton, GA
NPI 1548622285 · NPPES record last updated Feb 28, 2019
Key facts
- NPI
- 1548622285
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- FOUR CORNERS PRIMARY CARE CENTERS INC
- Practice address
- 115 Towne Center Pkwy
Suite 113
Hoschton, GA 30548-2213 - Phone
- (770) 806-2928
- NPI assigned
- Mar 22, 2016
- Organization subpart
- No
Authorized official
- Name
- Brian Willams, MD
- Title
- Ceo
- Phone
- (770) 806-2928
Other NPIs with the same Medicare PAC ID 3
Corporate family (same tax ID) 3
Practitioners 9
-
Eric Benning, M.D.
-
Wardah Khalid, PA-C
-
Karima N Sohani, FNP-C,FNP-BC, AGNP-C
-
William A Holley, DPM
-
Aziz A Pirani, MD
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in GA
Federally qualified health center certification: CCN 111059
- Legal name
- FOUR CORNERS PRIMARY CARE CENTERS, INC.
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- May 19, 2016
- Last certification
- May 19, 2016
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- May 6, 2007 in GA
- Enrollment address
- 115 Towne Center Pkwy
Ste 113
Hoschton, GA 30548-2222
All disclosed owners & managing parties 13
| Name | Role | Since | Share |
|---|---|---|---|
| Angel G Amaro |
Corporate Officer |
Mar 1, 2016 | |
| William G Mayfield |
Corporate Officer |
Mar 1, 2016 | |
| Walter Murray |
Corporate Officer |
Mar 1, 2016 | |
| W-2 Managing Employee |
Mar 1, 2016 | ||
| Vanessa M Robinson-Dooley |
Corporate Officer |
Mar 1, 2016 | |
| Brian O Williams |
5% Or Greater Direct Ownership Interest |
Mar 1, 2016 | |
| Corporate Officer |
Mar 1, 2016 | ||
| W-2 Managing Employee |
Mar 1, 2016 | ||
| Rossana Mangual |
Corporate Officer |
Mar 1, 2016 | |
| Four Corners Primary Care Centers Inc |
5% Or Greater Direct Ownership Interest | Mar 1, 2016 | 100% |
| Mary Jane Labonte |
Corporate Officer |
Mar 1, 2016 | |
| Angela F Watkins |
Corporate Officer |
Mar 1, 2016 | |
| Eric L Banum |
Corporate Officer |
Mar 1, 2016 | |
| Julie a Crosby- San Miguel |
Corporate Officer |
Mar 1, 2016 | |
| Cappel Sookdeu |
Corporate Officer |
Mar 1, 2016 | |
| Lily Arfa Morehouse |
Corporate Officer |
Mar 1, 2016 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20160519002463 | GA | Part a Provider - Federally Qualified Health Center (FQHC) | 1951497494 | Practice locations: Hoschton, GA |
National Provider Directory
- Tax ID family
- Four Corners Prim Care
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
115 Towne Center Pkwy
Suite 113
Hoschton, GA 30548-2213
Mailing address
5300 Oakbrook Pkwy
Suite 130
Norcross, GA 30093-2256
Other providers in Hoschton, GA
- Ennisons Homecare LLC
- Charlotte Hart Fandrich
- First Look MRI, LLC
- Tonya M Flewellen
- Kassia Florentine
- Franklin Ezeoke
- Curtina Freeman Rahming
- Megan Jackson Thacker Fusco
- Heather Chelsey Futral
- Katherine Lovin Gee
All providers in Hoschton, GA · Federally Qualified Health Center (FQHC) in Georgia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 28, 2019. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.