Healthcare Provider Details

I. General information

NPI: 1720627748
Provider Name (Legal Business Name): NORTHEAST GEORGIA PHYSICIANS GROUP-URGENT CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2019
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

852 DACULA RD
DACULA GA
30019-3185
US

IV. Provider business mailing address

PO BOX 1060
OAKWOOD GA
30566-0018
US

V. Phone/Fax

Practice location:
  • Phone: 770-848-9380
  • Fax:
Mailing address:
  • Phone: 770-219-8721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LISA HERNANDEZ
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 770-219-8420