Provider Demographics
NPI:1215132527
Name:ATHENS GYNECOLOGY PC
Entity type:Organization
Organization Name:ATHENS GYNECOLOGY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:706-548-4424
Mailing Address - Street 1:1580 TREE LN
Mailing Address - Street 2:PO BOX 325
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2207
Mailing Address - Country:US
Mailing Address - Phone:770-978-7246
Mailing Address - Fax:770-979-8348
Practice Address - Street 1:1270 PRINCE AVENUE
Practice Address - Street 2:SUITE 202
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606
Practice Address - Country:US
Practice Address - Phone:706-548-4424
Practice Address - Fax:706-548-4880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000084763BMedicaid
D40334Medicare UPIN
GA000084763BMedicaid