Basic Information
| Provider Information | |||||||||
| NPI: | 1740237213 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BULLOCH COUNTY ENDOSCOPY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 537022 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303537022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048887575 | ||||||||
| FaxNumber: | 4048857777 | ||||||||
| Practice Location | |||||||||
| Address1: | 1555 BRAMPTON AVE | ||||||||
| Address2: | |||||||||
| City: | STATESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304580856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126812007 | ||||||||
| FaxNumber: | 9126811489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 10/28/2011 | ||||||||
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| AuthorizedOfficialLastName: | MORRIS | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| 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 | 261QA1903X | 016-298 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 003110301A | 05 | GA | MEDICAID |