Basic Information
| Provider Information | |||||||||
| NPI: | 1245352327 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GASTROINTESTINAL ASSOCIATES ENDOSCOPY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2510 LAKELAND DR | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392329513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013551234 | ||||||||
| FaxNumber: | 6013263566 | ||||||||
| Practice Location | |||||||||
| Address1: | 2510 LAKELAND DR | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392329513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013551234 | ||||||||
| FaxNumber: | 6013263566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2007 | ||||||||
| LastUpdateDate: | 12/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | DOTHEROW | ||||||||
| AuthorizedOfficialFirstName: | PIERCE | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6013551234 | ||||||||
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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 | 25C0001033 | MS | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
| ID | Type | State | Issuer | Description | 00770495 | 05 | MS | MEDICAID |