Provider Demographics
NPI:1255312807
Name:NORTHEAST GEORGIA CANCER SPECIALIST, PC
Entity type:Organization
Organization Name:NORTHEAST GEORGIA CANCER SPECIALIST, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:G
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:770-535-3393
Mailing Address - Street 1:PO BOX 2418
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-2418
Mailing Address - Country:US
Mailing Address - Phone:770-693-6022
Mailing Address - Fax:770-693-6039
Practice Address - Street 1:NORTHEAST GEORGIA MEDICAL CENTER
Practice Address - Street 2:743 SPRING STREET
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501
Practice Address - Country:US
Practice Address - Phone:770-535-3393
Practice Address - Fax:770-503-0579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty