Provider Demographics
NPI:1740305408
Name:GEORGIA BREAST CARE, P.C.
Entity type:Organization
Organization Name:GEORGIA BREAST CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, GEORGIA BREAST CARE
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:ROUSE
Authorized Official - Last Name:WACHSMUTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-370-0370
Mailing Address - Street 1:900 TOWNE LAKE PKWY STE 312
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-1604
Mailing Address - Country:US
Mailing Address - Phone:678-370-0370
Mailing Address - Fax:678-370-0371
Practice Address - Street 1:900 TOWNE LAKE PKWY STE 312
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-1604
Practice Address - Country:US
Practice Address - Phone:678-370-0370
Practice Address - Fax:678-370-0371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA47200208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6823Medicare ID - Type Unspecified
GAG98367Medicare UPIN