=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154312312
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER EDWARD FONG M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2005
-----------------------------------------------------
Last Update Date | 04/08/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 106 ALLEN ST
-----------------------------------------------------
City | CUMMING
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30040-2602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-549-8114
-----------------------------------------------------
Fax | 706-549-0151
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 80883
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30608-0883
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-549-8114
-----------------------------------------------------
Fax | 706-549-0151
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | 056467
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207LA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | 56467
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------