1801924857 NPI number — NORTHWEST GEORGIA ONCOLOGY CENTERS, PC

Table of content: KELLEE JEAN ANDERSON APRN (NPI 1811616584)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801924857 NPI number — NORTHWEST GEORGIA ONCOLOGY CENTERS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST GEORGIA ONCOLOGY CENTERS, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801924857
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
620 J L WHITE DR
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
JASPER
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30143-4896
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-682-9016
Provider Business Practice Location Address Fax Number:
706-253-0177
Provider Enumeration Date:
03/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOULD
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
MD PHYSICIAN
Authorized Official Telephone Number:
770-281-5100

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  074178000 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1801924857 . This is a "SUPPLIER NPI NUMBER (JASPER)" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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