Healthcare Provider Details

I. General information

NPI: 1447443387
Provider Name (Legal Business Name): NORTHEAST GEORGIA SPECIALTY GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S ENOTA DR NE SUITE Q
GAINESVILLE GA
30501-2400
US

IV. Provider business mailing address

601 S ENOTA DR NE SUITE Q
GAINESVILLE GA
30501-2400
US

V. Phone/Fax

Practice location:
  • Phone: 770-533-8400
  • Fax: 770-533-8409
Mailing address:
  • Phone: 770-533-8400
  • Fax: 770-533-8409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MARK KLEIN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 770-533-8406