Provider Demographics
NPI:1538103049
Name:NORTHEAST GEORGIA PHYSICIANS GROUP, INC.
Entity Type:Organization
Organization Name:NORTHEAST GEORGIA PHYSICIANS GROUP, INC.
Other - Org Name:MEDICAL TRANSPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE-PRESIDENT & CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:M
Authorized Official - Last Name:HERDENER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-219-9000
Mailing Address - Street 1:743 SPRING ST NE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3715
Mailing Address - Country:US
Mailing Address - Phone:770-219-9000
Mailing Address - Fax:770-219-0561
Practice Address - Street 1:665 LANIER PARK DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2059
Practice Address - Country:US
Practice Address - Phone:770-219-0303
Practice Address - Fax:770-219-0561
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST GEORGIA HEALTH SYSTEM, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-15
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA154-033416L0300X
GA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00793625BMedicaid
GA00793625BMedicaid
GA00793625BMedicaid
GA00793625BMedicaid
GA59RCBLQMedicare Oscar/Certification