=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679658702
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GWINNETT INFECTIOUS DISEASES PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 07/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1960 RIVERSIDE PKWY SUITE 101
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30043-5945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-995-0466
-----------------------------------------------------
Fax | 770-995-0472
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1960 RIVERSIDE PKWY SUITE 101
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30043-5945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-995-0466
-----------------------------------------------------
Fax | 770-995-0472
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ELLIOT G RAIZES
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 770-995-0466
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------