Healthcare Provider Details

I. General information

NPI: 1023039385
Provider Name (Legal Business Name): NORTHEAST GEORGIA PLASTIC SURGERY ASSOCIATES, PLASTIC SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 08/22/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1296 SIMS ST SUITE B
GAINESVILLE GA
30501-3850
US

IV. Provider business mailing address

1296 SIMS ST SUITE B
GAINESVILLE GA
30501-3850
US

V. Phone/Fax

Practice location:
  • Phone: 770-534-1856
  • Fax: 770-531-0355
Mailing address:
  • Phone: 770-534-1856
  • Fax: 770-531-0355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number069-037
License Number StateGA

VIII. Authorized Official

Name: SAMUEL W. RICHWINE JR.
Title or Position: MEDICAL DIRECTOR
Credential: M. D.
Phone: 770-534-1856