1619005667 NPI number — NORTHWEST GEORGIA ONCOLOGY CENTERS, PC

Table of content: (NPI 1619005667)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619005667 NPI number — NORTHWEST GEORGIA ONCOLOGY CENTERS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST GEORGIA ONCOLOGY CENTERS, 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:
1619005667
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1700 HOSPITAL SOUTH DR
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
AUSTELL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30106-6810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-944-2830
Provider Business Mailing Address Fax Number:
678-581-7170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
705 DALLAS HWY
Provider Second Line Business Practice Location Address:
STE 205
Provider Business Practice Location Address City Name:
VILLA RICA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30180-1247
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-771-5935
Provider Business Practice Location Address Fax Number:
770-456-3407
Provider Enumeration Date:
03/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOULD
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
MD PHYSICIAN
Authorized Official Telephone Number:
770-281-5100

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  074178000 , 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: 169005667 . This is a "SUPPLIER NUMBER (VILLA RICA)" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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