Basic Information
| Provider Information | |||||||||
| NPI: | 1225452931 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGESTIVE HEALTHCARE OF GA, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DIGESTIVE HEALTHCARE OF GA BLUE RIDGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 RIVERSTONE VIS | ||||||||
| Address2: | SUITE 217 | ||||||||
| City: | BLUE RIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305136648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066328008 | ||||||||
| FaxNumber: | 7066328070 | ||||||||
| Practice Location | |||||||||
| Address1: | 95 COLLIER ROAD | ||||||||
| Address2: | SUITE 4075 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046033543 | ||||||||
| FaxNumber: | 4043508795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2014 | ||||||||
| LastUpdateDate: | 02/17/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBINSON | ||||||||
| AuthorizedOfficialFirstName: | SHELLY | ||||||||
| AuthorizedOfficialMiddleName: | MONIQUE | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4046033543 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 207R0000X | GA | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | 207RG0100X | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.