Provider Demographics
NPI:1821275629
Name:NORTHWEST GEORGIA ONCOLOGY CENTERS, P.C
Entity Type:Organization
Organization Name:NORTHWEST GEORGIA ONCOLOGY CENTERS, P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOULD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-281-5000
Mailing Address - Street 1:531 ROSELANE ST NW
Mailing Address - Street 2:SUITE 710
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-6913
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:340 KENNESTONE HOSPITAL BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1152
Practice Address - Country:US
Practice Address - Phone:770-281-5115
Practice Address - Fax:678-581-7111
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST GEORGIA ONCOLOGY CENTERS,P.C
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-24
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
GAPHRE0094453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0741780001Medicare NSC
GAGRP245Medicare PIN