Provider Demographics
NPI:1851340871
Name:UROLOGY CLINIC NORTHWEST, PC
Entity Type:Organization
Organization Name:UROLOGY CLINIC NORTHWEST, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:G
Authorized Official - Last Name:MYGATT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-942-5227
Mailing Address - Street 1:3025 BRECKINRIDGE BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-7611
Mailing Address - Country:US
Mailing Address - Phone:678-226-0022
Mailing Address - Fax:
Practice Address - Street 1:8954 HOSPITAL DR
Practice Address - Street 2:SUITE 115D
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2272
Practice Address - Country:US
Practice Address - Phone:770-942-5227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020462208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GRP131Medicare ID - Type Unspecified