Healthcare Provider Details

I. General information

NPI: 1497861900
Provider Name (Legal Business Name): NORTHEAST GEORGIA SURGICAL ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 JESSE JEWELL PKWY NE STE B
GAINESVILLE GA
30501-3814
US

IV. Provider business mailing address

1075 JESSE JEWELL PKWY NE STE B
GAINESVILLE GA
30501-3814
US

V. Phone/Fax

Practice location:
  • Phone: 770-536-5733
  • Fax: 770-532-8007
Mailing address:
  • Phone: 770-536-5733
  • Fax: 770-532-8007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. GAIL DETRAZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 770-536-5733