Healthcare Provider Details

I. General information

NPI: 1659794691
Provider Name (Legal Business Name): GWINNETT EAR NOSE & THROAT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2014
Last Update Date: 01/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3855 PLEASANT HILL RD SUITE 280
DULUTH GA
30096-1407
US

IV. Provider business mailing address

3855 PLEASANT HILL RD SUITE 280
DULUTH GA
30096-1407
US

V. Phone/Fax

Practice location:
  • Phone: 470-325-0100
  • Fax: 470-325-0193
Mailing address:
  • Phone: 470-325-0100
  • Fax: 470-325-0193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: STEVEN A RUBIN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 470-325-0150