1205803699 NPI number — GI DIAGNOSTICS ENDOSCOPY CENTER, LLC

Table of content: (NPI 1205803699)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205803699 NPI number — GI DIAGNOSTICS ENDOSCOPY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GI DIAGNOSTICS ENDOSCOPY CENTER, LLC
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:
1205803699
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
711 CANTON RD NE STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30060-8949
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-741-2317
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2550 WINDY HILL RD SE
Provider Second Line Business Practice Location Address:
STE. 302
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30067-8665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-226-9070
Provider Business Practice Location Address Fax Number:
770-951-9016
Provider Enumeration Date:
03/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
TRACY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
SENIOR MANAGER, BUSINESS OPERATIONS
Authorized Official Telephone Number:
678-819-4295

Provider Taxonomy Codes

  • Taxonomy code: 261QE0800X , with the licence number:  6800013 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QE0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000805384A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003119778A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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