Provider Demographics
NPI:1184667925
Name:GREATER GWINNETT PHYSICIAN PRACTICE COMPANY
Entity type:Organization
Organization Name:GREATER GWINNETT PHYSICIAN PRACTICE COMPANY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-982-9450
Mailing Address - Street 1:1800 TREE LN
Mailing Address - Street 2:STE. 120
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2016
Mailing Address - Country:US
Mailing Address - Phone:770-982-9450
Mailing Address - Fax:
Practice Address - Street 1:1800 TREE LN
Practice Address - Street 2:STE. 120
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2016
Practice Address - Country:US
Practice Address - Phone:770-982-9450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6092Medicare ID - Type UnspecifiedCAHABA MEDICARE/ GA MEDIC
GADA6928Medicare ID - Type UnspecifiedRAILROAD MEDICARE