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General NPI Number Information
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NPI Number | 1003140351
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Entity Type | Organization
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Legal Business Name | CARDIOVASCULAR GROUP
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Dates
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Enumeration Date | 09/18/2009
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Last Update Date | 10/03/2012
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Provider Practice Location Address
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Address Line | 755 WALTHER RD
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-8725
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Country | US
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Telephone | 678-252-3707
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Fax |
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Provider Business Mailing Address
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Address Line | 1051 STONE SHOALS CT
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City | WATKINSVILLE
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State | GA
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Zip | 30677-2774
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN ASSISTANT
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Name | MRS. MARIAH WOOD THAXTON
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Credential | PA-C
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Telephone | 478-457-7128
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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