Provider Demographics
NPI:1740823202
Name:GWINNETT PULMONARY GROUP DULUTH
Entity type:Organization
Organization Name:GWINNETT PULMONARY GROUP DULUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS-ROLOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-942-5985
Mailing Address - Street 1:631 PROFESSIONAL DR STE 350
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3370
Mailing Address - Country:US
Mailing Address - Phone:770-995-0630
Mailing Address - Fax:
Practice Address - Street 1:3855 PLEASANT HILL RD STE 180
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-8093
Practice Address - Country:US
Practice Address - Phone:770-995-0630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GWINNETT PULMONARY GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-28
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA555819545SAMedicaid