1053462325 NPI number — NORTHWEST GEORGIA MEDICAL CLINIC, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053462325 NPI number — NORTHWEST GEORGIA MEDICAL CLINIC, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST GEORGIA MEDICAL CLINIC, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053462325
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 RIVERBEND DR SW
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
ROME
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30161-6065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-378-5651
Provider Business Mailing Address Fax Number:
706-378-8267

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 RIVERBEND DR SW
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
ROME
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30161-6065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-378-5651
Provider Business Practice Location Address Fax Number:
706-378-8267
Provider Enumeration Date:
01/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
ANGIE
Authorized Official Middle Name:
Authorized Official Title or Position:
FINANCIAL COORD
Authorized Official Telephone Number:
706-378-5651

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CL0326 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com