Basic Information
| Provider Information | |||||||||
| NPI: | 1023252954 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GASTRO SPECIALISTS ENDOSCOPY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3292 MOUNTAIN DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300321102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042948180 | ||||||||
| FaxNumber: | 4042948180 | ||||||||
| Practice Location | |||||||||
| Address1: | 3292 MOUNTAIN DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300321102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042948180 | ||||||||
| FaxNumber: | 4042948188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2009 | ||||||||
| LastUpdateDate: | 08/19/2010 | ||||||||
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| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | SHIRLEY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4042948180 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
No ID Information.