Provider Demographics
NPI:1154864841
Name:NORTHWEST GEORGIA ONCOLOGY CENTERS, PC
Entity Type:Organization
Organization Name:NORTHWEST GEORGIA ONCOLOGY CENTERS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D./ MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOULD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-281-5100
Mailing Address - Street 1:1700 HOSPITAL SOUTH DRIVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-8116
Mailing Address - Country:US
Mailing Address - Phone:770-944-2830
Mailing Address - Fax:678-581-7170
Practice Address - Street 1:2500 HOSPITAL BOULEVARD
Practice Address - Street 2:SUITE 490
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4907
Practice Address - Country:US
Practice Address - Phone:470-321-7500
Practice Address - Fax:678-355-4474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-29
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1154864841OtherNPI NUMBER