Healthcare Provider Details

I. General information

NPI: 1790948578
Provider Name (Legal Business Name): ATLANTA GWINNETT OBGYN ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

766 WALTHER RD SUITE 100
LAWRENCEVILLE GA
30045-8726
US

IV. Provider business mailing address

766 WALTHER ROAD SUITE 100
LAWRENCEVILLE GA
30045
US

V. Phone/Fax

Practice location:
  • Phone: 678-985-8001
  • Fax: 678-985-8002
Mailing address:
  • Phone: 678-985-8001
  • Fax: 678-985-8002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number034593
License Number StateGA

VIII. Authorized Official

Name: DR. GREGORY FOUNTAIN
Title or Position: PRESIDENT
Credential: MD
Phone: 678-985-8001