Provider Demographics
NPI:1265577159
Name:NOVA OBGYN, PC
Entity type:Organization
Organization Name:NOVA OBGYN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:NELDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-994-6806
Mailing Address - Street 1:1587 PHOENIX BLVD
Mailing Address - Street 2:SUITE6
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-5540
Mailing Address - Country:US
Mailing Address - Phone:770-994-6806
Mailing Address - Fax:770-994-6807
Practice Address - Street 1:1587 PHOENIX BLVD
Practice Address - Street 2:SUITE6
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-5540
Practice Address - Country:US
Practice Address - Phone:770-994-6806
Practice Address - Fax:770-994-6807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3978Medicare PIN