Provider Demographics
NPI:1124183355
Name:NORTHEAST GEORGIA MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:NORTHEAST GEORGIA MEDICAL CENTER, INC.
Other - Org Name:DBA NGMC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:STEINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-219-3562
Mailing Address - Street 1:PO BOX 741891
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1891
Mailing Address - Country:US
Mailing Address - Phone:770-538-7559
Mailing Address - Fax:
Practice Address - Street 1:825 JESSE JEWELL PKWY SE
Practice Address - Street 2:SUITE D
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3830
Practice Address - Country:US
Practice Address - Phone:770-538-7559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1119987OtherNCPDP
GA00608583AMedicaid
GAPHRE007738OtherSTATE LICENSE
GAPHRE007738OtherSTATE LICENSE
GA00608583AMedicaid