Healthcare Provider Details

I. General information

NPI: 1689014763
Provider Name (Legal Business Name): CPC-GATEWAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2013
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4039 GATEWAY BLVD
GROVETOWN GA
30813-3195
US

IV. Provider business mailing address

PO BOX 1967
EVANS GA
30809-1967
US

V. Phone/Fax

Practice location:
  • Phone: 706-922-1600
  • Fax: 706-922-1010
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL FRIEDMAN
Title or Position: MD
Credential:
Phone: 706-922-1600