Provider Demographics
NPI:1437217734
Name:NORTHEAST GEORGIA OTOLARYNGOLOGY
Entity Type:Organization
Organization Name:NORTHEAST GEORGIA OTOLARYNGOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:FARMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-536-4352
Mailing Address - Street 1:2406 LIGHTHOUSE MANOR DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-7401
Mailing Address - Country:US
Mailing Address - Phone:770-536-4352
Mailing Address - Fax:770-532-8165
Practice Address - Street 1:2406 LIGHTHOUSE MANOR DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-7401
Practice Address - Country:US
Practice Address - Phone:770-536-4352
Practice Address - Fax:770-532-8165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3285Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER