Provider Demographics
NPI:1689711558
Name:MATERNAL GYNERATIONS, PC
Entity Type:Organization
Organization Name:MATERNAL GYNERATIONS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:WIIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-513-4000
Mailing Address - Street 1:761 OLD NORCROSS RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4317
Mailing Address - Country:US
Mailing Address - Phone:770-513-4000
Mailing Address - Fax:770-995-3495
Practice Address - Street 1:761 OLD NORCROSS RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4317
Practice Address - Country:US
Practice Address - Phone:770-513-4000
Practice Address - Fax:770-995-3495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACJ3628OtherPALMETTO GBA RAILROAD
GACJ3628OtherPALMETTO GBA RAILROAD