Provider Demographics
NPI:1396803755
Name:GWINNETT INTERNAL MEDICINE ASSOCIATES LLC
Entity type:Organization
Organization Name:GWINNETT INTERNAL MEDICINE ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MGR.
Authorized Official - Prefix:
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GEARHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-963-2474
Mailing Address - Street 1:601 OLD NORCROSS RD
Mailing Address - Street 2:STE A
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4311
Mailing Address - Country:US
Mailing Address - Phone:770-963-2474
Mailing Address - Fax:770-963-2476
Practice Address - Street 1:601 OLD NORCROSS RD
Practice Address - Street 2:STE A
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4311
Practice Address - Country:US
Practice Address - Phone:770-963-2474
Practice Address - Fax:770-963-2476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA19511207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAC35215Medicare PIN
GAG45206Medicare UPIN
GA119525393BMedicare PIN
GAD45213Medicare PIN
GAD45213Medicare UPIN
GA11BDLXJMedicare PIN
GAG39541Medicare UPIN
GAE00995Medicare UPIN
GA337647983AMedicare PIN
GA11SCFRTMedicare PIN
GA119524780CMedicare PIN