Basic Information
| Provider Information | |||||||||
| NPI: | 1003889346 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ENDOSCOPY GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4810 N DAVIS HWY | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325032341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504778109 | ||||||||
| FaxNumber: | 8504789903 | ||||||||
| Practice Location | |||||||||
| Address1: | 4810 N DAVIS HWY | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325032341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504748988 | ||||||||
| FaxNumber: | 8504789903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 03/01/2018 | ||||||||
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| AuthorizedOfficialLastName: | DUNN | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR/CFO | ||||||||
| AuthorizedOfficialTelephone: | 8504748988 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 490003997 | 01 | RAILROAD MEDICARE | OTHER | 5121097 | 01 | AETNA | OTHER | 3804534 | 01 | CIGNA | OTHER | 987585 | 01 | USA HEALTH NETWORK | OTHER | 079204700 | 05 | FL | MEDICAID | 65B | 01 | HEALTH OPTIONS | OTHER |