Provider Demographics
NPI:1972640852
Name:NORTHEAST GA SURGICAL HEALTHCARE
Entity Type:Organization
Organization Name:NORTHEAST GA SURGICAL HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EARLE
Authorized Official - Middle Name:WALCOTT
Authorized Official - Last Name:GUNN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:706-549-5554
Mailing Address - Street 1:740 PRINCE AVE
Mailing Address - Street 2:BLGD 8B
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-5908
Mailing Address - Country:US
Mailing Address - Phone:706-549-5554
Mailing Address - Fax:706-548-7056
Practice Address - Street 1:740 PRINCE AVE
Practice Address - Street 2:BLGD 8B
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-5908
Practice Address - Country:US
Practice Address - Phone:706-549-5554
Practice Address - Fax:706-548-7056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD45512Medicare UPIN
GA02BDHWTMedicare ID - Type UnspecifiedGA MEDICARE