Provider Demographics
NPI:1407023005
Name:EXECUTIVE OB-GYN, PC
Entity Type:Organization
Organization Name:EXECUTIVE OB-GYN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:TOLLEY
Authorized Official - Last Name:WHELAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, CNM
Authorized Official - Phone:770-795-0850
Mailing Address - Street 1:635 GOLDENWOOD CT
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-6406
Mailing Address - Country:US
Mailing Address - Phone:770-795-0850
Mailing Address - Fax:770-429-0446
Practice Address - Street 1:635 GOLDENWOOD CT
Practice Address - Street 2:
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-6406
Practice Address - Country:US
Practice Address - Phone:770-795-0850
Practice Address - Fax:770-429-0446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR59280251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care