Basic Information
| Provider Information | |||||||||
| NPI: | 1124277058 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIGESTIVE HEALTHCARE OF GEORGIA ENDOSCOPY CENTER MOUNTAINSIDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95 COLLIER RD NW | ||||||||
| Address2: | SUITE 4075 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043553200 | ||||||||
| FaxNumber: | 4043509316 | ||||||||
| Practice Location | |||||||||
| Address1: | 134 MOUNTAINSIDE VILLAGE PARKWAY | ||||||||
| Address2: | BLDG 500 | ||||||||
| City: | JASPER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301434895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062537340 | ||||||||
| FaxNumber: | 7062537342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2008 | ||||||||
| LastUpdateDate: | 08/26/2009 | ||||||||
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| AuthorizedOfficialLastName: | PENNINGTON | ||||||||
| AuthorizedOfficialFirstName: | GAYE | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4046033543 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIGESTIVE HEALTHCARE OF GEORGIA ENDOSCOPY CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 400647725A | 05 | GA | MEDICAID |