Provider Demographics
NPI:1205916483
Name:NORTHEAST GEORGIA UROLOGICAL ASSOC., P.C.
Entity type:Organization
Organization Name:NORTHEAST GEORGIA UROLOGICAL ASSOC., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BIRD
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-535-0000
Mailing Address - Street 1:660 LANIER PARK DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2075
Mailing Address - Country:US
Mailing Address - Phone:770-535-0000
Mailing Address - Fax:770-532-3911
Practice Address - Street 1:660 LANIER PARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2075
Practice Address - Country:US
Practice Address - Phone:770-535-0000
Practice Address - Fax:770-532-3911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021167174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0793530002Medicare NSC