Healthcare Provider Details

I. General information

NPI: 1538103049
Provider Name (Legal Business Name): NORTHEAST GEORGIA PHYSICIANS GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 LANIER PARK DR
GAINESVILLE GA
30501-2059
US

IV. Provider business mailing address

743 SPRING ST NE
GAINESVILLE GA
30501-3715
US

V. Phone/Fax

Practice location:
  • Phone: 770-219-0303
  • Fax: 770-219-0561
Mailing address:
  • Phone: 770-219-9000
  • Fax: 770-219-0561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number154-03
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateGA

VIII. Authorized Official

Name: MR. ANTHONY M. HERDENER
Title or Position: VICE-PRESIDENT & CFO
Credential:
Phone: 770-219-9000