Basic Information
| Provider Information | |||||||||
| NPI: | 1720015993 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEAST GEORGIA MEDICAL CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | REHAB UNIT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 741891 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303741891 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702199000 | ||||||||
| FaxNumber: | 7702196694 | ||||||||
| Practice Location | |||||||||
| Address1: | 743 SPRING ST NE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702199000 | ||||||||
| FaxNumber: | 7702196694 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 04/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STEINES | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7702193562 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTHEAST GEORGIA MEDICAL CENTER INC. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | GA | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 000000888A | 05 | GA | MEDICAID |