Basic Information
Provider Information | |||||||||
NPI: | 1558553859 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GASTROINTESTINAL ASSOCIATES ENDOSCOPY CENTER, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2510 LAKELAND DR | ||||||||
Address2: |   | ||||||||
City: | FLOWOOD | ||||||||
State: | MS | ||||||||
PostalCode: | 392329513 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6013551234 | ||||||||
FaxNumber: | 6013263566 | ||||||||
Practice Location | |||||||||
Address1: | 106 HIGHLAND WAY STE 101 | ||||||||
Address2: |   | ||||||||
City: | MADISON | ||||||||
State: | MS | ||||||||
PostalCode: | 391106930 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6013551234 | ||||||||
FaxNumber: | 6013263566 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/10/2007 | ||||||||
LastUpdateDate: | 12/06/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DOTHEROW | ||||||||
AuthorizedOfficialFirstName: | PIERCE | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
AuthorizedOfficialTelephone: | 6013551234 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | GASTROINTESTINAL ASSOCIATES ENDOSCOPY CENTER, LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | 25C0001070 | MS | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
ID | Type | State | Issuer | Description | 07328281 | 05 | MS |   | MEDICAID |