Provider Demographics
NPI:1528196888
Name:NORTHWEST PLAZA ASC LLC
Entity Type:Organization
Organization Name:NORTHWEST PLAZA ASC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-435-0525
Mailing Address - Street 1:2311 LAKE PARK DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-3183
Mailing Address - Country:US
Mailing Address - Phone:229-435-0525
Mailing Address - Fax:229-434-9827
Practice Address - Street 1:2311 LAKE PARK DR
Practice Address - Street 2:SUITE 4
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-3183
Practice Address - Country:US
Practice Address - Phone:229-435-0525
Practice Address - Fax:229-434-9827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA35890261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA20BBFKNMedicare ID - Type Unspecified
GAF41795Medicare UPIN