Healthcare Provider Details

I. General information

NPI: 1396049383
Provider Name (Legal Business Name): GWINNETT SURGICAL ASSOCIATES, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2011
Last Update Date: 01/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 PROFESSIONAL DR SUITE 300
LAWRENCEVILLE GA
30046-3367
US

IV. Provider business mailing address

631 PROFESSIONAL DR SUITE 300
LAWRENCEVILLE GA
30046-3367
US

V. Phone/Fax

Practice location:
  • Phone: 770-962-9977
  • Fax: 770-339-9804
Mailing address:
  • Phone: 770-962-9977
  • Fax: 770-339-9804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. WALLACE FORD MARTIN
Title or Position: MANAGING PARTNER
Credential: MD
Phone: 770-962-9977