Provider Demographics
NPI:1760565808
Name:N.W. GEORGIA CARDIOLOGY CLINIC,P.C.
Entity Type:Organization
Organization Name:N.W. GEORGIA CARDIOLOGY CLINIC,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D./OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLANIYI
Authorized Official - Middle Name:OLABODE
Authorized Official - Last Name:OSOFISAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-529-7922
Mailing Address - Street 1:3459 ACWORTH DUE WEST RD NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-5819
Mailing Address - Country:US
Mailing Address - Phone:770-529-7922
Mailing Address - Fax:770-529-7931
Practice Address - Street 1:3459 ACWORTH DUE WEST RD NW
Practice Address - Street 2:SUITE 559
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-5819
Practice Address - Country:US
Practice Address - Phone:770-529-7922
Practice Address - Fax:770-529-7931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053797207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA173191749AMedicaid
GA173191749AMedicaid
GAGRP6870Medicare PIN