Basic Information
| Provider Information | |||||||||
| NPI: | 1760778765 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GASTROINTESTINAL DIAGNOSTIC ENDOSCOPY WOODSTOCK, LLC | ||||||||
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| OtherOrganizationName: | TOWN LAKE ENDOSCOPY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2550 WINDY HILL RD SE | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300678665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6787415000 | ||||||||
| FaxNumber: | 6787412301 | ||||||||
| Practice Location | |||||||||
| Address1: | 118 MILL ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WOODSTOCK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301884879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702269070 | ||||||||
| FaxNumber: | 7702268863 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2011 | ||||||||
| LastUpdateDate: | 03/11/2015 | ||||||||
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| AuthorizedOfficialLastName: | ROWELL | ||||||||
| AuthorizedOfficialFirstName: | DEBORA | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6787412317 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | N | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy | 261QA1903X | 028-451 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.