Basic Information
| Provider Information | |||||||||
| NPI: | 1689197378 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CVG PHYSICIANS GROUP, LLC | ||||||||
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| OtherOrganizationName: | CARDIOVASCULAR GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 RIVERSIDE PKWY STE 119B-319 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300435927 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 755 WALTHER RD | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300468725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709620399 | ||||||||
| FaxNumber: | 7709950533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | SANDLER | ||||||||
| AuthorizedOfficialFirstName: | MANFRED | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7709620399 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 003196217A | 05 | GA | MEDICAID |