Provider Demographics
NPI:1194991695
Name:NORTHEAST GEORGIA GYNECOLOGY
Entity type:Organization
Organization Name:NORTHEAST GEORGIA GYNECOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:G
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-532-9250
Mailing Address - Street 1:440 WASHINGTON ST SE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3619
Mailing Address - Country:US
Mailing Address - Phone:770-532-9250
Mailing Address - Fax:770-532-4242
Practice Address - Street 1:440 WASHINGTON ST SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3619
Practice Address - Country:US
Practice Address - Phone:770-532-9250
Practice Address - Fax:770-532-4242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046837261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6368OtherMEDICARE GROUP PIN
GAH52815Medicare UPIN
GA16BBCGRMedicare PIN