Provider Demographics
NPI:1629406780
Name:UNIVERSITY OF NORTHGEORGIA
Entity Type:Organization
Organization Name:UNIVERSITY OF NORTHGEORGIA
Other - Org Name:APPALACHIAN NURSE PRACTITIONER CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:PROJECT DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDSON-GALLOGLY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, APRN-BC
Authorized Official - Phone:706-864-1934
Mailing Address - Street 1:82 COLLEGE CIRCLE
Mailing Address - Street 2:HNS BUILDING, SUITE102
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30597-0001
Mailing Address - Country:US
Mailing Address - Phone:706-867-2713
Mailing Address - Fax:706-867-3249
Practice Address - Street 1:82 COLLEGE CIRCLE
Practice Address - Street 2:HNS BUILDING, SUITE102
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30597-0001
Practice Address - Country:US
Practice Address - Phone:706-867-2713
Practice Address - Fax:706-867-3249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-28
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA169909261QP2300X
GA113863261QP2300X
GA053488261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003132118AMedicaid
GA003134646AMedicaid
GA539432806BMedicaid