Basic Information
Provider Information | |||||||||
NPI: | 1710049036 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GWINNETT CONSULTANTS IN CARDIOLOGY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 631 PROFESSIONAL DR | ||||||||
Address2: | STE 360 | ||||||||
City: | LAWRENCEVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 300463367 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709624895 | ||||||||
FaxNumber: | 7709624792 | ||||||||
Practice Location | |||||||||
Address1: | 631 PROFESSIONAL DRIVE | ||||||||
Address2: | STE 360 | ||||||||
City: | LAWRENCEVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 300460000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709624895 | ||||||||
FaxNumber: | 7709624792 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/14/2006 | ||||||||
LastUpdateDate: | 04/16/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BAHIN | ||||||||
AuthorizedOfficialFirstName: | RACHEL | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7709624895 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 55000865A | 05 | GA |   | MEDICAID |