Provider Demographics
NPI:1326392689
Name:NORTHEAST GEORGIA MEDICAL CENTER
Entity Type:Organization
Organization Name:NORTHEAST GEORGIA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MID LEVEL PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:FAIRCHILDS
Authorized Official - Suffix:
Authorized Official - Credentials:ACNP-BC
Authorized Official - Phone:864-314-9526
Mailing Address - Street 1:115 MELIA LN
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29625-6361
Mailing Address - Country:US
Mailing Address - Phone:864-314-9526
Mailing Address - Fax:
Practice Address - Street 1:115 MELIA LN
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29625-6361
Practice Address - Country:US
Practice Address - Phone:864-314-9526
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-07
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN205146363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty