Provider Demographics
NPI:1598895500
Name:HERITAGE OB GYN, PC
Entity Type:Organization
Organization Name:HERITAGE OB GYN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-531-1515
Mailing Address - Street 1:668 LANIER PARK DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2061
Mailing Address - Country:US
Mailing Address - Phone:770-531-1515
Mailing Address - Fax:770-538-0517
Practice Address - Street 1:668 LANIER PARK DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2061
Practice Address - Country:US
Practice Address - Phone:770-531-1515
Practice Address - Fax:770-538-0517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2489OtherMEDICARE GROUP NUMBER