Provider Demographics
NPI:1821082645
Name:ETOWAH VALLEY OBSTETRICS & GYNECOLOGY, P.C.
Entity Type:Organization
Organization Name:ETOWAH VALLEY OBSTETRICS & GYNECOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BEN
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-382-5611
Mailing Address - Street 1:970 JOE FRANK HARRIS PKWY SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-2159
Mailing Address - Country:US
Mailing Address - Phone:770-382-5611
Mailing Address - Fax:770-382-8381
Practice Address - Street 1:970 JOE FRANK HARRIS PKWY SE
Practice Address - Street 2:SUITE 200
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-2159
Practice Address - Country:US
Practice Address - Phone:770-382-5611
Practice Address - Fax:770-382-8381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032492174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00443022EMedicaid
GAE62040Medicare UPIN
GA16BDCSHMedicare ID - Type Unspecified