Provider Demographics
NPI:1982634572
Name:GWINNETT HOSPITAL SYSTEM, INC.
Entity Type:Organization
Organization Name:GWINNETT HOSPITAL SYSTEM, INC.
Other - Org Name:SUMMITRIDGE CENTER FOR PSYCHIATRY AND ADDICTION MEDICINE
Other - Org Type:Other Name
Authorized Official - Title/Position:SR. VP., CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:Y
Authorized Official - Last Name:MCBRIDE
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:678-442-4308
Mailing Address - Street 1:PO BOX 1190
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-1190
Mailing Address - Country:US
Mailing Address - Phone:678-442-5622
Mailing Address - Fax:770-339-3459
Practice Address - Street 1:250 SCENIC HWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-5675
Practice Address - Country:US
Practice Address - Phone:678-442-5622
Practice Address - Fax:770-339-3459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067-460273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000294AMedicaid
11S087Medicare ID - Type UnspecifiedMEDICARE