Healthcare Provider Details

I. General information

NPI: 1831228865
Provider Name (Legal Business Name): GWINNETT OB GYN ASSOC. 2 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 TREE LN SUITE 290
SNELLVILLE GA
30078-6782
US

IV. Provider business mailing address

PO BOX 468329
ATLANTA GA
31146-8329
US

V. Phone/Fax

Practice location:
  • Phone: 404-943-0205
  • Fax:
Mailing address:
  • Phone: 404-943-0205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ALICIA HOLDEN
Title or Position: LEAD
Credential: ACCOUNTING
Phone: 404-943-0205