Provider Demographics
NPI:1861413197
Name:NORTH GEORGIA UROLOGY CENTER, PC, INC
Entity type:Organization
Organization Name:NORTH GEORGIA UROLOGY CENTER, PC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CLISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:TALLENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-278-5961
Mailing Address - Street 1:1434 BROADRICK DRIVE
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-3009
Mailing Address - Country:US
Mailing Address - Phone:706-278-5961
Mailing Address - Fax:706-275-0280
Practice Address - Street 1:1434 BROADRICK DRIVE
Practice Address - Street 2:NORTH GEORGIA UROLOGY CENTER
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720
Practice Address - Country:US
Practice Address - Phone:706-278-5961
Practice Address - Fax:706-275-0280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050482208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00931312AMedicaid
GA429126502AMedicaid
GA8913681Medicaid
GAGRP6470Medicare ID - Type Unspecified
GA8913681Medicaid
GAQ17488Medicare UPIN
GA00931312AMedicaid