Provider Demographics
NPI:1750458261
Name:SPECIALTY GYNECOLOGY PC
Entity type:Organization
Organization Name:SPECIALTY GYNECOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:CASTAGNO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-672-4666
Mailing Address - Street 1:2398 MOUNT VERNON RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-3064
Mailing Address - Country:US
Mailing Address - Phone:770-512-7099
Mailing Address - Fax:770-512-7090
Practice Address - Street 1:2398 MOUNT VERNON RD
Practice Address - Street 2:SUITE 150
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-3064
Practice Address - Country:US
Practice Address - Phone:770-512-7099
Practice Address - Fax:770-512-7090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031498207VE0102X
GA044759207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive EndocrinologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000772285BMedicaid
GA000772285BMedicaid
F05797Medicare UPIN