Healthcare Provider Details

I. General information

NPI: 1780747469
Provider Name (Legal Business Name): GWINNETT MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 02/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MEDICAL CENTER BLVD
LAWRENCEVILLE GA
30046-7694
US

IV. Provider business mailing address

PO BOX 116156
ATLANTA GA
30368-6156
US

V. Phone/Fax

Practice location:
  • Phone: 678-312-5525
  • Fax: 770-339-2120
Mailing address:
  • Phone: 470-325-0136
  • Fax: 470-325-0191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateGA
# 6
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateGA

VIII. Authorized Official

Name: MR. STEVEN A RUBIN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 470-325-0150