Healthcare Provider Details

I. General information

NPI: 1053672378
Provider Name (Legal Business Name): MRS. MARY BETH SWAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2012
Last Update Date: 12/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1290 ATHENS ST
GAINESVILLE GA
30507-7000
US

IV. Provider business mailing address

1290 ATHENS ST
GAINESVILLE GA
30507-7000
US

V. Phone/Fax

Practice location:
  • Phone: 770-531-5600
  • Fax: 770-535-5342
Mailing address:
  • Phone: 770-531-5600
  • Fax: 770-535-5342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: