MEDICARE: NORTHEAST GEORGIA PHYSICIANS GROUP, INC.

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	207KA0200X	Allergy Physician

General Provider Information

NPI Number	:	1134749211
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST GEORGIA PHYSICIANS GROUP, INC.

Provider Business Mailing Address
First Line	:	1515 RIVER PL STE 380
Second Line	:
City	:	BRASELTON
State	:	GA
Zip	:	30517-5605
Country	:	US
Telephone Number	:	770-848-9345
Fax Number	:

Provider Business Practice Location Address
First Line	:	1515 RIVER PL STE 380
Second Line	:
City	:	BRASELTON
State	:	GA
Zip	:	30517-5605
Country	:	US
Telephone Number	:	770-848-9345
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR PHYSICIAN SERVIC
Name	:	SHELBY ANN DODD
Credential	:
Telephone Number	:	770-219-8453

Provider Enumeration Date	:	04/20/2020
Last Update Date	:	04/20/2020

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