Basic Information
| Provider Information | |||||||||
| NPI: | 1124156310 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST GEORGIA ONCOLOGY CENTERS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 HOSPITAL SOUTH DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301066810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709442830 | ||||||||
| FaxNumber: | 6785817170 | ||||||||
| Practice Location | |||||||||
| Address1: | 157 CLINIC AVE | ||||||||
| Address2: | STE 101 | ||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301174454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703332220 | ||||||||
| FaxNumber: | 6785817180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2007 | ||||||||
| LastUpdateDate: | 12/01/2010 | ||||||||
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| AuthorizedOfficialLastName: | GOULD | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MD PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 7702815100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 0741780006 | GA | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 1124156310 | 01 | GA | SUPPLIER NPI NUMBER (CARROLLTON) | OTHER |