Basic Information
| Provider Information | |||||||||
| NPI: | 1659794691 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GWINNETT EAR NOSE & THROAT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3855 PLEASANT HILL RD | ||||||||
| Address2: | SUITE 280 | ||||||||
| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300961407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4703250100 | ||||||||
| FaxNumber: | 4703250193 | ||||||||
| Practice Location | |||||||||
| Address1: | 3855 PLEASANT HILL RD | ||||||||
| Address2: | SUITE 280 | ||||||||
| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300961407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4703250100 | ||||||||
| FaxNumber: | 4703250193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2014 | ||||||||
| LastUpdateDate: | 01/28/2014 | ||||||||
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| AuthorizedOfficialLastName: | RUBIN | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4703250150 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GWINNETT MEDICAL GROUP, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.