NPIMap

Organization Active NPI

Northeast Georgia Physicians Group, Inc.

  • Sports Medicine (Family Medicine) Physician
  • Hoschton, GA
National Provider Identifier
1104009059
Registry record updated Apr 15, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Sports Medicine (Family Medicine) PhysicianTaxonomy code 207QS0010X
License
60363 Issued in GA
Legal business name
NORTHEAST GEORGIA PHYSICIANS GROUP, INC.
Practice address
115 Towne Center Pkwy
Suite 113
Hoschton, GA 30548-2213
Phone
(706) 658-2452
Fax
(706) 658-2462
NPI assigned
Dec 14, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 15, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. J. Shannon Glover
Title
Exec. Director Managed Care
Phone
(770) 219-7826

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Sports Medicine (Family Medicine) PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207QS0010X 60363 GA Primary

Addresses

Primary practice location

115 Towne Center Pkwy
Suite 113
Hoschton, GA 30548-2213

Mailing address

115 Towne Center Pkwy
Suite 113
Hoschton, GA 30548-2213
Phone (706) 658-2452

Other identifiers 1

IdentifierTypeStateIssuer
574554373AMedicaidGA

National Provider Directory

National Provider Directory
Tax ID family
Northeast Georgia Primary5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1197590400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1302825600000",
    "number": "1104009059",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "115 TOWNE CENTER PKWY",
            "address_2": "SUITE 113",
            "city": "HOSCHTON",
            "state": "GA",
            "postal_code": "305482213",
            "telephone_number": "706-658-2452",
            "fax_number": "706-658-2462"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "115 TOWNE CENTER PKWY",
            "address_2": "SUITE 113",
            "city": "HOSCHTON",
            "state": "GA",
            "postal_code": "305482213",
            "telephone_number": "706-658-2452",
            "fax_number": "706-658-2462"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHEAST GEORGIA PHYSICIANS GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-12-14",
        "last_updated": "2011-04-15",
        "status": "A",
        "authorized_official_last_name": "GLOVER",
        "authorized_official_first_name": "J.",
        "authorized_official_middle_name": "SHANNON",
        "authorized_official_title_or_position": "EXEC. DIRECTOR MANAGED CARE",
        "authorized_official_telephone_number": "770-219-7826",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207QS0010X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Family Medicine, Sports Medicine",
            "state": "GA",
            "license": "60363",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "574554373A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Hoschton, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 15, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.