Basic Information
| Provider Information | |||||||||
| NPI: | 1811977648 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GEORGIA CANCER TREATMENT AND HEMATOLOGY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 483 UPPER RIVERDALE RD | ||||||||
| Address2: | STE E | ||||||||
| City: | RIVERDALE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709091550 | ||||||||
| FaxNumber: | 7709091535 | ||||||||
| Practice Location | |||||||||
| Address1: | 1279 HWY 54 W | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707191299 | ||||||||
| FaxNumber: | 7707199244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GOLDKLANG | ||||||||
| AuthorizedOfficialFirstName: | GERALD | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7707191299 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 020714 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | BG6599059 | 01 | DEA | OTHER | 00188801C | 05 | GA | MEDICAID |