Healthcare Provider Details

I. General information

NPI: 1629607809
Provider Name (Legal Business Name): QIAOCHU GU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 06/11/2023
Certification Date: 06/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 HOSPITAL DR
TOCCOA GA
30577-6820
US

IV. Provider business mailing address

163 HOSPITAL DR
TOCCOA GA
30577-6820
US

V. Phone/Fax

Practice location:
  • Phone: 706-282-4200
  • Fax:
Mailing address:
  • Phone: 423-778-7628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0000064963
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number94998
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: