Provider Demographics
NPI:1922167360
Name:NORTH GEORGIA NEUROLOGICAL CLINIC PC
Entity Type:Organization
Organization Name:NORTH GEORGIA NEUROLOGICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-995-0555
Mailing Address - Street 1:600 PROFESSIONAL DRIVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-7638
Mailing Address - Country:US
Mailing Address - Phone:770-995-0555
Mailing Address - Fax:770-995-0682
Practice Address - Street 1:600 PROFESSIONAL DRIVE
Practice Address - Street 2:SUITE 110
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7638
Practice Address - Country:US
Practice Address - Phone:770-995-0555
Practice Address - Fax:770-995-0682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2084N0400X
GA0357892084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP941Medicare ID - Type Unspecified
GAGRP00941Medicare PIN