Basic Information
| Provider Information | |||||||||
| NPI: | 1194776674 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GWINNETT OB-GYN ASSOCIATES, P.C.. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 TREE LANE RD | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300786782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709720330 | ||||||||
| FaxNumber: | 7709852683 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 TREE LANE RD | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300786782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709720330 | ||||||||
| FaxNumber: | 7709852683 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 06/22/2015 | ||||||||
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| AuthorizedOfficialLastName: | GANN | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7709720330 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics |
ID Information
| ID | Type | State | Issuer | Description | 055000257A | 05 | GA | MEDICAID | CA866 | 01 | RAILROAD MEDICARE | OTHER |