MEDICARE: NORTHWEST GEORGIA ONCOLOGY CENTERS, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	0741780004	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1083742175	OTHER	GA	NPI SUPPLIER NUMBER (CARTERSVILLE)

General Provider Information

NPI Number	:	1083742175
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWEST GEORGIA ONCOLOGY CENTERS, PC

Provider Business Mailing Address
First Line	:	1700 HOSPITAL SOUTH DR
Second Line	:	SUITE 300
City	:	AUSTELL
State	:	GA
Zip	:	30106-6810
Country	:	US
Telephone Number	:	770-944-2830
Fax Number	:	678-581-7170

Provider Business Practice Location Address
First Line	:	100 MARKET PLACE BLVD
Second Line	:	STE 200
City	:	CARTERSVILLE
State	:	GA
Zip	:	30121-8718
Country	:	US
Telephone Number	:	770-386-7253
Fax Number	:	770-382-6424

Authorized Official
Title or Position	:	MD PHYSICIAN
Name	:	DR. BRUCE J GOULD
Credential	:	MD
Telephone Number	:	770-281-5100

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	12/01/2010

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