Basic Information
| Provider Information | |||||||||
| NPI: | 1275871147 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PANOLA ENDOSCOPY CENTER LLC | ||||||||
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| OtherOrganizationName: | PANOLA ENDOSCOPY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 PEACHTREE ST NE | ||||||||
| Address2: | SUITE 1600 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303082208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048887575 | ||||||||
| FaxNumber: | 4048857777 | ||||||||
| Practice Location | |||||||||
| Address1: | 5403 HILLANDALE PARK COURT | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LITHONIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708170224 | ||||||||
| FaxNumber: | 7708170228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2013 | ||||||||
| LastUpdateDate: | 01/28/2013 | ||||||||
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| AuthorizedOfficialLastName: | BAKER | ||||||||
| AuthorizedOfficialFirstName: | JANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4048887575 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
No ID Information.