Provider Demographics
NPI:1891737425
Name:GREATER GWINNETT PHYSICIAN PRACTICE COMPANY
Entity Type:Organization
Organization Name:GREATER GWINNETT PHYSICIAN PRACTICE COMPANY
Other - Org Name:MOUNTAIN EAST FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-661-3365
Mailing Address - Street 1:4120 FIVE FORKS TRICKUM RD SW
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3130
Mailing Address - Country:US
Mailing Address - Phone:770-921-6900
Mailing Address - Fax:
Practice Address - Street 1:4120 FIVE FORKS TRICKUM RD SW
Practice Address - Street 2:SUITE 105
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3130
Practice Address - Country:US
Practice Address - Phone:770-921-6900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACH1940Medicare ID - Type UnspecifiedRAILROAD MEDICARE
GAGRP3053Medicare ID - Type UnspecifiedCAHABA MEDICARE/ GA MEDIC