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General NPI Number Information
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NPI Number | 1952676496
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Entity Type | Organization
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Legal Business Name | GWINNETT CLINIC, LTD
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Dates
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Enumeration Date | 03/16/2012
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Last Update Date | 01/25/2023
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Provider Practice Location Address
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Address Line | 3475 PIEDMONT RD NE STE 1150
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City | ATLANTA
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State | GA
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Zip | 30305-3003
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Country | US
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Telephone | 770-995-3300
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Fax | 770-995-3307
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Provider Business Mailing Address
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Address Line | 10600 MEDLOCK BRIDGE RD
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City | DULUTH
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State | GA
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Zip | 30097-8404
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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 | AUTHORIZED OFFICIAL
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Name | DEEP SHAH
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Credential | MD, MSC
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Telephone | 770-995-3300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 173000000X
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Taxonomy Name | Legal Medicine
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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