Healthcare Provider Details

I. General information

NPI: 1316200579
Provider Name (Legal Business Name): GWINNETT MEDICAL SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 06/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 GLENLEAF DR
NORCROSS GA
30092-6104
US

IV. Provider business mailing address

414 GLENLEAF DR
NORCROSS GA
30092-6104
US

V. Phone/Fax

Practice location:
  • Phone: 720-226-0652
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateGA

VIII. Authorized Official

Name: MR. OTIS L BONNER III
Title or Position: ATTORNEY
Credential:
Phone: 770-485-1329