Basic Information
| Provider Information | |||||||||
| NPI: | 1831134121 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VALDOSTA ENDOSCOPY CENTER, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 410 CONNELL RD | ||||||||
| Address2: | |||||||||
| City: | VALDOSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 316021407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292441570 | ||||||||
| FaxNumber: | 2292471084 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 CONNELL RD | ||||||||
| Address2: | |||||||||
| City: | VALDOSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 316021407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292441570 | ||||||||
| FaxNumber: | 2292471084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 06/08/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WARD | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2292441570 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | 092-243 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
| ID | Type | State | Issuer | Description | 000960473A | 05 | GA | MEDICAID |