Basic Information
| Provider Information | |||||||||
| NPI: | 1548206493 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHERN CRESCENT ENDOSCOPY SUITE, LLC | ||||||||
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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: | 5671 PEACHTREE DUNWOODY RD NE | ||||||||
| Address2: | SUITE 680 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303425000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047056985 | ||||||||
| FaxNumber: | 4048519950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 08/24/2011 | ||||||||
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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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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
| ID | Type | State | Issuer | Description | 543655296A | 05 | GA | MEDICAID |