Basic Information
| Provider Information | |||||||||
| NPI: | 1659384329 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ENDOSCOPY CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1139 LEXINGTON AVE STE B | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123034200 | ||||||||
| FaxNumber: | 9127902701 | ||||||||
| Practice Location | |||||||||
| Address1: | 1139 LEXINGTON AVE STE B | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123034200 | ||||||||
| FaxNumber: | 9127902701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 09/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | MARINI | ||||||||
| AuthorizedOfficialFirstName: | LYNNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9123034200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | 02406 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
| ID | Type | State | Issuer | Description | 976125519A | 05 | GA | MEDICAID |