Provider Demographics
NPI:1407988702
Name:GWINNETT NEUROSURGICAL, PC
Entity Type:Organization
Organization Name:GWINNETT NEUROSURGICAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER OF PATIENT ACCOUNTS
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-995-5333
Mailing Address - Street 1:753 OLD NORCROSS RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-4312
Mailing Address - Country:US
Mailing Address - Phone:770-995-5333
Mailing Address - Fax:770-995-5322
Practice Address - Street 1:753 OLD NORCROSS RD
Practice Address - Street 2:SUITE A
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-4312
Practice Address - Country:US
Practice Address - Phone:770-995-5333
Practice Address - Fax:770-995-5322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE64486Medicare UPIN
GA14BDBZXMedicare ID - Type UnspecifiedMEDICARE PROV#