1871529529 NPI number — GASTROENTEROLOGY OF NORTHEAST GEORGIA PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871529529 NPI number — GASTROENTEROLOGY OF NORTHEAST GEORGIA PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GASTROENTEROLOGY OF NORTHEAST GEORGIA PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871529529
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 759
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLAIRSVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30514-0759
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-745-8800
Provider Business Mailing Address Fax Number:
706-745-8805

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 HOSPITAL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLAIRSVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30512-3139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-745-8800
Provider Business Practice Location Address Fax Number:
706-745-8805
Provider Enumeration Date:
06/24/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
AINSWORTH
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
W
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
706-745-8800

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 122605 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 376554453A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 890633G , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 435212000 . This is a "CHAMPUS/TRICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 005857 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".