Healthcare Provider Details

I. General information

NPI: 1407988702
Provider Name (Legal Business Name): GWINNETT NEUROSURGICAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

753 OLD NORCROSS RD SUITE A
LAWRENCEVILLE GA
30045-4312
US

IV. Provider business mailing address

753 OLD NORCROSS RD SUITE A
LAWRENCEVILLE GA
30045-4312
US

V. Phone/Fax

Practice location:
  • Phone: 770-995-5333
  • Fax: 770-995-5322
Mailing address:
  • Phone: 770-995-5333
  • Fax: 770-995-5322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number StateGA

VIII. Authorized Official

Name: KEVIN L ANDERSON
Title or Position: MANAGER OF PATIENT ACCOUNTS
Credential:
Phone: 770-995-5333