MEDICARE: N.W. GEORGIA CARDIOLOGY CLINIC,P.C.

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	207RC0000X	Cardiovascular Disease Physician	053797	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760565808
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	N.W. GEORGIA CARDIOLOGY CLINIC,P.C.

Provider Business Mailing Address
First Line	:	3459 ACWORTH DUE WEST RD NW
Second Line	:
City	:	ACWORTH
State	:	GA
Zip	:	30101-5819
Country	:	US
Telephone Number	:	770-529-7922
Fax Number	:	770-529-7931

Provider Business Practice Location Address
First Line	:	3459 ACWORTH DUE WEST RD NW
Second Line	:	SUITE 559
City	:	ACWORTH
State	:	GA
Zip	:	30101-5819
Country	:	US
Telephone Number	:	770-529-7922
Fax Number	:	770-529-7931

Authorized Official
Title or Position	:	M.D./OWNER
Name	:	DR. OLANIYI OLABODE OSOFISAN
Credential	:	M.D.
Telephone Number	:	770-529-7922

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	09/26/2011

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