Healthcare Provider Details

I. General information

NPI: 1447698964
Provider Name (Legal Business Name): GEORGIA NORTHSIDE EAR, NOSE AND THROAT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2013
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 UPPER HEMBREE RD SUITE 201
ROSWELL GA
30076-1171
US

IV. Provider business mailing address

PO BOX 742566
ATLANTA GA
30374-2105
US

V. Phone/Fax

Practice location:
  • Phone: 770-475-3361
  • Fax: 770-664-4431
Mailing address:
  • Phone: 770-475-3361
  • Fax: 770-664-4431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. WESLEY O. JAMES
Title or Position: REGIONAL CFO, TENET
Credential:
Phone: 404-265-5009