Provider Demographics
NPI:1205919404
Name:ALLERGY AND ENT OF GA
Entity type:Organization
Organization Name:ALLERGY AND ENT OF GA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:JETER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-867-4311
Mailing Address - Street 1:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533-0025
Mailing Address - Country:US
Mailing Address - Phone:706-864-1356
Mailing Address - Fax:706-864-1356
Practice Address - Street 1:227 MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-1606
Practice Address - Country:US
Practice Address - Phone:706-867-4306
Practice Address - Fax:706-864-1356
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN HEALTH CORPORATION OF DAHLONEGA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-23
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADC7827OtherRAILROAD MEDICARE GROUP #
GADC7827OtherRAILROAD MEDICARE GROUP #