Provider Demographics
NPI:1982701124
Name:WEST GEORGIA UROLOGY ASSOCIATES PC
Entity type:Organization
Organization Name:WEST GEORGIA UROLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:MORIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-834-6988
Mailing Address - Street 1:150 CLINIC AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4402
Mailing Address - Country:US
Mailing Address - Phone:770-834-6988
Mailing Address - Fax:
Practice Address - Street 1:150 CLINIC AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4402
Practice Address - Country:US
Practice Address - Phone:770-834-6988
Practice Address - Fax:770-834-1090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0438940001OtherPALMETTO GBA
GA0438940001OtherPALMETTO GBA
GAGRP3256Medicare PIN