1972640852 NPI number — NORTHEAST GA SURGICAL HEALTHCARE

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 1972640852 NPI number — NORTHEAST GA SURGICAL HEALTHCARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST GA SURGICAL HEALTHCARE
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:
1972640852
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
740 PRINCE AVE
Provider Second Line Business Mailing Address:
BLGD 8B
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30606-5908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-549-5554
Provider Business Mailing Address Fax Number:
706-548-7056

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
740 PRINCE AVE
Provider Second Line Business Practice Location Address:
BLGD 8B
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30606-5908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-549-5554
Provider Business Practice Location Address Fax Number:
706-548-7056
Provider Enumeration Date:
01/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GUNN
Authorized Official First Name:
EARLE
Authorized Official Middle Name:
WALCOTT
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
706-549-5554

Provider Taxonomy Codes

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

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





Copyright © 2007-2026 www.npivalidator.com