Healthcare Provider Details

I. General information

NPI: 1689711558
Provider Name (Legal Business Name): MATERNAL GYNERATIONS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 12/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

761 OLD NORCROSS RD
LAWRENCEVILLE GA
30046-4317
US

IV. Provider business mailing address

761 OLD NORCROSS RD
LAWRENCEVILLE GA
30046-4317
US

V. Phone/Fax

Practice location:
  • Phone: 770-513-4000
  • Fax: 770-995-3495
Mailing address:
  • Phone: 770-513-4000
  • Fax: 770-995-3495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: LANCE J WIIST
Title or Position: VICE PRESIDENT
Credential:
Phone: 770-513-4000