Healthcare Provider Details

I. General information

NPI: 1396803755
Provider Name (Legal Business Name): GWINNETT INTERNAL MEDICINE ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 02/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 OLD NORCROSS RD STE A
LAWRENCEVILLE GA
30046-4311
US

IV. Provider business mailing address

601 OLD NORCROSS RD STE A
LAWRENCEVILLE GA
30046-4311
US

V. Phone/Fax

Practice location:
  • Phone: 770-963-2474
  • Fax: 770-963-2476
Mailing address:
  • Phone: 770-963-2474
  • Fax: 770-963-2476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number19511
License Number StateGA

VIII. Authorized Official

Name: LYNDA GEARHART
Title or Position: PRACTICE MGR.
Credential:
Phone: 770-963-2474