Basic Information
| Provider Information | |||||||||
| NPI: | 1962869446 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAYETTEVILLE GASTROENTEROLOGY ENDOSCOPY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2041 VALLEYGATE DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283043745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103235203 | ||||||||
| FaxNumber: | 9103233650 | ||||||||
| Practice Location | |||||||||
| Address1: | 2041 VALLEYGATE DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283043745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103235203 | ||||||||
| FaxNumber: | 9103233650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2016 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | VORDER BRUEGGE | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9103235203 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D, | ||||||||
| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | NC | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | Q591940001 | 01 | NC | MEDICARE | OTHER |