Healthcare Provider Details

I. General information

NPI: 1053462325
Provider Name (Legal Business Name): NORTHWEST GEORGIA MEDICAL CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 RIVERBEND DR SW STE 200
ROME GA
30161-6065
US

IV. Provider business mailing address

15 RIVERBEND DR SW STE 200
ROME GA
30161-6065
US

V. Phone/Fax

Practice location:
  • Phone: 706-378-5651
  • Fax: 706-378-8267
Mailing address:
  • Phone: 706-378-5651
  • Fax: 706-378-8267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANGIE SMITH
Title or Position: FINANCIAL COORD
Credential:
Phone: 706-378-5651