Basic Information
| Provider Information | |||||||||
| NPI: | 1942546452 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GASTROINTESTINAL SPECIALISTS FOUNDATION, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 405827 | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303845800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015782538 | ||||||||
| FaxNumber: | 9015782572 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 HUMPHREYS CENTER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381202352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015782538 | ||||||||
| FaxNumber: | 9015782572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2013 | ||||||||
| LastUpdateDate: | 12/16/2019 | ||||||||
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| AuthorizedOfficialLastName: | DUCKETT | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP/CLO | ||||||||
| AuthorizedOfficialTelephone: | 9012275233 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/16/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | AR | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207ZP0102X | TN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 363LF0000X | TN | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 367500000X | TN | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207RG0100X | TN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 201055002 | 05 | AR | MEDICAID | 201063002 | 05 | AR | MEDICAID |