Healthcare Provider Details

I. General information

NPI: 1104009059
Provider Name (Legal Business Name): NORTHEAST GEORGIA PHYSICIANS GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2007
Last Update Date: 04/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 TOWNE CENTER PKWY SUITE 113
HOSCHTON GA
30548-2213
US

IV. Provider business mailing address

115 TOWNE CENTER PKWY SUITE 113
HOSCHTON GA
30548-2213
US

V. Phone/Fax

Practice location:
  • Phone: 706-658-2452
  • Fax: 706-658-2462
Mailing address:
  • Phone: 706-658-2452
  • Fax: 706-658-2462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number60363
License Number StateGA

VIII. Authorized Official

Name: MR. J. SHANNON GLOVER
Title or Position: EXEC. DIRECTOR MANAGED CARE
Credential:
Phone: 770-219-7826