Healthcare Provider Details

I. General information

NPI: 1750376695
Provider Name (Legal Business Name): NORTHWEST GEORGIA ONCOLOGY CENTERS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 06/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 KENNESTONE HOSPITAL BLVD SUITE 200
MARIETTA GA
30060-1121
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 TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number032740
License Number StateGA

VIII. Authorized Official

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