MEDICARE: GWINNETT CLINIC, LTD

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207R00000X	Internal Medicine Physician
2	261QP2300X	Primary Care Clinic/Center
3	363L00000X	Nurse Practitioner
4	207Q00000X	Family Medicine Physician
5	173000000X	Legal Medicine
6	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1790939163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GWINNETT CLINIC, LTD

Provider Business Mailing Address
First Line	:	10600 MEDLOCK BRIDGE RD
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30097-8404
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1383 ATLANTA HWY NW
Second Line	:
City	:	AUBURN
State	:	GA
Zip	:	30011-3224
Country	:	US
Telephone Number	:	678-407-7891
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	DEEP SHAH
Credential	:	MD, MSC
Telephone Number	:	770-995-3300

Provider Enumeration Date	:	11/11/2008
Last Update Date	:	01/25/2023

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