1003814716 NPI number — DR. JOHN P GORECKI MD

Table of content: DR. JOHN P GORECKI MD (NPI 1003814716)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003814716 NPI number — DR. JOHN P GORECKI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORECKI
Provider First Name:
JOHN
Provider Middle Name:
P
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1003814716
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33 BUFORD VILLAGE WAY
Provider Second Line Business Mailing Address:
SUITE 325
Provider Business Mailing Address City Name:
BUFORD
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30518-8843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-730-7796
Provider Business Mailing Address Fax Number:
678-730-7786

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 NORTHSIDE FORSYTH DR
Provider Second Line Business Practice Location Address:
SUITE 310
Provider Business Practice Location Address City Name:
CUMMING
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30041-6012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-730-7796
Provider Business Practice Location Address Fax Number:
678-730-7786
Provider Enumeration Date:
07/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  0429019 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X , with the licence number: 62853 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 372501099B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100387000A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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