Provider Demographics
NPI:1700914926
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 200
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 1:200 ALLEN MEMORIAL DR
Practice Address - Street 2:STE 302-B
Practice Address - City:BREMEN
Practice Address - State:GA
Practice Address - Zip Code:30110-2012
Practice Address - Country:US
Practice Address - Phone:770-824-2222
Practice Address - Fax:770-824-2426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA074178000332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1700914926OtherSUPPLIER NPI NUMBER (BREMEN)
GA0741780011Medicare NSC