Provider Demographics
NPI:1366607434
Name:GWINNETT GYNECOLOGY AND OBSTETRICS
Entity type:Organization
Organization Name:GWINNETT GYNECOLOGY AND OBSTETRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ROE
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-963-1340
Mailing Address - Street 1:500 MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-8708
Mailing Address - Country:US
Mailing Address - Phone:770-963-1340
Mailing Address - Fax:770-963-2073
Practice Address - Street 1:500 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-8708
Practice Address - Country:US
Practice Address - Phone:770-963-1340
Practice Address - Fax:770-963-2073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA24238207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD45384Medicare UPIN