Provider Demographics
NPI:1649308685
Name:NORTHWEST GEORGIA ONCOLOGY CENTERS
Entity type:Organization
Organization Name:NORTHWEST GEORGIA ONCOLOGY CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOULD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-281-5100
Mailing Address - Street 1:1700 HOSPITAL SOUTH DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-6810
Mailing Address - Country:US
Mailing Address - Phone:770-944-2830
Mailing Address - Fax:678-581-7170
Practice Address - Street 1:561 DEEP SOUTH FARM RD
Practice Address - Street 2:STE 2
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-2289
Practice Address - Country:US
Practice Address - Phone:706-835-1589
Practice Address - Fax:706-835-2284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA074178000332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0741780010Medicare NSC