Provider Demographics
NPI:1063507630
Name:NORTHEAST GEORGIA PROCEDURE CENTER LLC
Entity Type:Organization
Organization Name:NORTHEAST GEORGIA PROCEDURE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAWNETTA
Authorized Official - Middle Name:JANENE
Authorized Official - Last Name:HOLLADAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-549-8114
Mailing Address - Street 1:P O BOX 80307
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30608-0307
Mailing Address - Country:US
Mailing Address - Phone:706-549-8114
Mailing Address - Fax:706-549-0151
Practice Address - Street 1:1620 PRINCE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6008
Practice Address - Country:US
Practice Address - Phone:706-549-8114
Practice Address - Fax:706-549-0151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029-303261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA938358734AMedicaid
GA938358734AMedicaid