Healthcare Provider Details

I. General information

NPI: 1255312807
Provider Name (Legal Business Name): NORTHEAST GEORGIA CANCER SPECIALIST, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NORTHEAST GEORGIA MEDICAL CENTER 743 SPRING STREET
GAINESVILLE GA
30501
US

IV. Provider business mailing address

PO BOX 2418
GAINESVILLE GA
30503-2418
US

V. Phone/Fax

Practice location:
  • Phone: 770-535-3393
  • Fax: 770-503-0579
Mailing address:
  • Phone: 770-693-6022
  • Fax: 770-693-6039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: FRANK G LAKE III
Title or Position: PRESIDENT
Credential: M.D.
Phone: 770-535-3393