Healthcare Provider Details

I. General information

NPI: 1700914751
Provider Name (Legal Business Name): NORTHWEST GEORGIA ONCOLOGY CENTERS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 KENNESTONE HOSPITAL BLVD STE 200
MARIETTA GA
30060-1152
US

IV. Provider business mailing address

1700 HOSPITAL SOUTH DR SUITE 300
AUSTELL GA
30106-6810
US

V. Phone/Fax

Practice location:
  • Phone: 770-281-5100
  • Fax: 678-581-7100
Mailing address:
  • Phone: 770-944-2830
  • Fax: 678-581-7170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number0741780001
License Number StateGA

VIII. Authorized Official

Name: DR. BRUCE J GOULD
Title or Position: MD PHYSICIAN
Credential: MD
Phone: 770-281-5100