1336375344 NPI number — GEORGIA CANCER SPECIALISTS I PC

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 1336375344 NPI number — GEORGIA CANCER SPECIALISTS I PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA CANCER SPECIALISTS I PC
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:
1336375344
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1835 SAVOY DR
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30341-1072
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-495-3396
Provider Business Mailing Address Fax Number:
770-495-2307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 FRANCIS WAY
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
SHARPSBURG
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30277-3589
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-253-9912
Provider Business Practice Location Address Fax Number:
770-253-9615
Provider Enumeration Date:
06/04/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LENZ
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
H
Authorized Official Title or Position:
C.O.O.
Authorized Official Telephone Number:
770-621-8656

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  20090002176 , 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)





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