Provider Demographics
NPI:1730110131
Name:NORTHLAKE PHYSICIAN PRACTICE NETWORK, INC.
Entity Type:Organization
Organization Name:NORTHLAKE PHYSICIAN PRACTICE NETWORK, INC.
Other - Org Name:WOMEN'S CANCER ALLIANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-938-3440
Mailing Address - Street 1:1459 MONTREAL RD
Mailing Address - Street 2:SUITE 408
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-6900
Mailing Address - Country:US
Mailing Address - Phone:770-938-3440
Mailing Address - Fax:
Practice Address - Street 1:1459 MONTREAL RD
Practice Address - Street 2:SUITE 408
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-6900
Practice Address - Country:US
Practice Address - Phone:770-938-3440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP5096Medicare ID - Type UnspecifiedGROUP NUMBER