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General NPI Number Information
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NPI Number | 1255312807
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Entity Type | Organization
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Legal Business Name | NORTHEAST GEORGIA CANCER SPECIALIST, PC
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Dates
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Enumeration Date | 11/10/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | NORTHEAST GEORGIA MEDICAL CENTER 743 SPRING STREET
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City | GAINESVILLE
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State | GA
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Zip | 30501
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Country | US
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Telephone | 770-535-3393
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Fax | 770-503-0579
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Provider Business Mailing Address
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Address Line | PO BOX 2418
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City | GAINESVILLE
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State | GA
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Zip | 30503-2418
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Country | US
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Telephone | 770-693-6022
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Fax | 770-693-6039
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Authorized Official
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Title or Position | PRESIDENT
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Name | FRANK G LAKE III
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Credential | M.D.
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Telephone | 770-535-3393
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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