Provider Demographics
NPI:1982978466
Name:NORTHWEST ENT SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:NORTHWEST ENT SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:M
Authorized Official - Last Name:EGEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-427-0368
Mailing Address - Street 1:960 WOODSTOCK PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-4866
Mailing Address - Country:US
Mailing Address - Phone:678-483-8833
Mailing Address - Fax:678-483-8809
Practice Address - Street 1:960 WOODSTOCK PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-4866
Practice Address - Country:US
Practice Address - Phone:678-483-8833
Practice Address - Fax:678-483-8809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-01
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA028-461OtherGEORGIA STATE LICENSE
GA028-461OtherGEORGIA STATE LICENSE