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

Table of content: (NPI 1053462325)

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".




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