Provider Demographics
NPI:1326144734
Name:GWINNETT CENTER MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:GWINNETT CENTER MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN'S ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:PETIT
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:770-277-8554
Mailing Address - Street 1:748 OLD NORCROSS RD
Mailing Address - Street 2:SUITE 185
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-3393
Mailing Address - Country:US
Mailing Address - Phone:770-277-8554
Mailing Address - Fax:770-277-1799
Practice Address - Street 1:748 OLD NORCROSS RD
Practice Address - Street 2:SUITE 185
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-3393
Practice Address - Country:US
Practice Address - Phone:770-277-8554
Practice Address - Fax:770-277-1799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001435363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00756104BMedicaid
GA97WCFDKMedicare ID - Type Unspecified
GA00756104BMedicaid