Basic Information
| Provider Information | |||||||||
| NPI: | 1689711558 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MATERNAL GYNERATIONS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 761 OLD NORCROSS RD | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300464317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705134000 | ||||||||
| FaxNumber: | 7709953495 | ||||||||
| Practice Location | |||||||||
| Address1: | 761 OLD NORCROSS RD | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300464317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705134000 | ||||||||
| FaxNumber: | 7709953495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 12/16/2011 | ||||||||
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| AuthorizedOfficialLastName: | WIIST | ||||||||
| AuthorizedOfficialFirstName: | LANCE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7705134000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | CJ3628 | 01 | GA | PALMETTO GBA RAILROAD | OTHER |