Healthcare Provider Details

I. General information

NPI: 1063507630
Provider Name (Legal Business Name): NORTHEAST GEORGIA PROCEDURE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 02/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 PRINCE AVE SUITE B
ATHENS GA
30606-6008
US

IV. Provider business mailing address

P O BOX 80307
ATHENS GA
30608-0307
US

V. Phone/Fax

Practice location:
  • Phone: 706-549-8114
  • Fax: 706-549-0151
Mailing address:
  • Phone: 706-549-8114
  • Fax: 706-549-0151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number029-303
License Number StateGA

VIII. Authorized Official

Name: DR. DAWNETTA JANENE HOLLADAY
Title or Position: CEO
Credential: M.D.
Phone: 706-549-8114