1053735761 NPI number — DIGESTIVE HEALTHCARE OF GA, P.C.

Table of content: (NPI 1053735761)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053735761 NPI number — DIGESTIVE HEALTHCARE OF GA, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIGESTIVE HEALTHCARE OF GA, P.C.
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:
6
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:
1053735761
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3280 HOWELL MILL RD NW STE T100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30327-4122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
140-460-3354
Provider Business Mailing Address Fax Number:
404-350-8795

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
433 HIGHLAND PKWY STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST ELLIJAY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30540-7658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-253-5514
Provider Business Practice Location Address Fax Number:
706-515-7203
Provider Enumeration Date:
02/17/2014

Additional Information

Authorized Official

Authorized Official Last Name:
ROBINSON
Authorized Official First Name:
SHELLY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
DIRECTOR RNC
Authorized Official Telephone Number:
404-603-3543

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  207RG0100X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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