Provider Demographics
NPI:1750376695
Name:NORTHWEST GEORGIA ONCOLOGY CENTERS, PC
Entity type:Organization
Organization Name:NORTHWEST GEORGIA ONCOLOGY CENTERS, PC
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 1:340 KENNESTONE HOSPITAL BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1121
Practice Address - Country:US
Practice Address - Phone:770-281-5100
Practice Address - Fax:678-581-7100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA333600000X, 3336C0003X, 3336S0011X
GA032740174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No333600000XSuppliersPharmacyGroup - Multi-Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300028463AMedicaid
GAGRP245OtherGROUP PTAN