Healthcare Provider Details

I. General information

NPI: 1437217734
Provider Name (Legal Business Name): NORTHEAST GEORGIA OTOLARYNGOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 11/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2406 LIGHTHOUSE MANOR DR
GAINESVILLE GA
30501-7401
US

IV. Provider business mailing address

2406 LIGHTHOUSE MANOR DR
GAINESVILLE GA
30501-7401
US

V. Phone/Fax

Practice location:
  • Phone: 770-536-4352
  • Fax: 770-532-8165
Mailing address:
  • Phone: 770-536-4352
  • Fax: 770-532-8165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ROGER WILLIAM FARMER
Title or Position: PARTNER
Credential: MD
Phone: 770-536-4352