Basic Information
| Provider Information | |||||||||
| NPI: | 1649441296 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GEORGIA CANCER SPECIALISTS I, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1835 SAVOY DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303411072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704953396 | ||||||||
| FaxNumber: | 7704952307 | ||||||||
| Practice Location | |||||||||
| Address1: | 7823 SPIVEY STATION BLVD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | JONESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302362886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706929371 | ||||||||
| FaxNumber: | 7706929375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2008 | ||||||||
| LastUpdateDate: | 03/30/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LENZ | ||||||||
| AuthorizedOfficialFirstName: | WENDY | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 7704965555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 037065 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.