Healthcare Provider Details

I. General information

NPI: 1952676496
Provider Name (Legal Business Name): GWINNETT CLINIC, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2012
Last Update Date: 01/25/2023
Certification Date: 01/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3475 PIEDMONT RD NE STE 1150
ATLANTA GA
30305-3003
US

IV. Provider business mailing address

10600 MEDLOCK BRIDGE RD
DULUTH GA
30097-8404
US

V. Phone/Fax

Practice location:
  • Phone: 770-995-3300
  • Fax: 770-995-3307
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DEEP SHAH
Title or Position: AUTHORIZED OFFICIAL
Credential: MD, MSC
Phone: 770-995-3300