Healthcare Provider Details

I. General information

NPI: 1982978466
Provider Name (Legal Business Name): NORTHWEST ENT SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2012
Last Update Date: 01/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 WOODSTOCK PKWY SUITE 101
WOODSTOCK GA
30188-4866
US

IV. Provider business mailing address

960 WOODSTOCK PKWY SUITE 101
WOODSTOCK GA
30188-4866
US

V. Phone/Fax

Practice location:
  • Phone: 678-483-8833
  • Fax: 678-483-8809
Mailing address:
  • Phone: 678-483-8833
  • Fax: 678-483-8809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CARLOS M EGEA
Title or Position: ADMINISTRATOR
Credential:
Phone: 770-427-0368