Provider Demographics
NPI:1104009059
Name:NORTHEAST GEORGIA PHYSICIANS GROUP, INC.
Entity Type:Organization
Organization Name:NORTHEAST GEORGIA PHYSICIANS GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC. DIRECTOR MANAGED CARE
Authorized Official - Prefix:MR
Authorized Official - First Name:J.
Authorized Official - Middle Name:SHANNON
Authorized Official - Last Name:GLOVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-219-7826
Mailing Address - Street 1:115 TOWNE CENTER PKWY
Mailing Address - Street 2:SUITE 113
Mailing Address - City:HOSCHTON
Mailing Address - State:GA
Mailing Address - Zip Code:30548-2213
Mailing Address - Country:US
Mailing Address - Phone:706-658-2452
Mailing Address - Fax:706-658-2462
Practice Address - Street 1:115 TOWNE CENTER PKWY
Practice Address - Street 2:SUITE 113
Practice Address - City:HOSCHTON
Practice Address - State:GA
Practice Address - Zip Code:30548-2213
Practice Address - Country:US
Practice Address - Phone:706-658-2452
Practice Address - Fax:706-658-2462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA60363207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA574554373AMedicaid