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General NPI Number Information
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NPI Number | 1891737425
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Entity Type | Organization
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Legal Business Name | GREATER GWINNETT PHYSICIAN PRACTICE COMPANY
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Dates
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Enumeration Date | 06/11/2006
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Last Update Date | 08/29/2007
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Provider Practice Location Address
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Address Line | 4120 FIVE FORKS TRICKUM RD SW SUITE 105
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City | LILBURN
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State | GA
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Zip | 30047-3130
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Country | US
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Telephone | 770-921-6900
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Fax |
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Provider Business Mailing Address
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Address Line | 4120 FIVE FORKS TRICKUM RD SW SUITE 105
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City | LILBURN
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State | GA
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Zip | 30047-3130
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Country | US
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Telephone | 770-921-6900
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Fax |
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Authorized Official
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Title or Position | VP
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Name | CHUCK LOCKE
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Credential |
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Telephone | 800-661-3365
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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