1386670404 NPI number — ADVANCED GASTROENTEROLOGY GROUP

Table of content: (NPI 1386670404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386670404 NPI number — ADVANCED GASTROENTEROLOGY GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED GASTROENTEROLOGY GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386670404
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4595 TOWNE LAKE PKWY
Provider Second Line Business Mailing Address:
BLDG 300, SUITE 200
Provider Business Mailing Address City Name:
WOODSTOCK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30189-5514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-509-0089
Provider Business Mailing Address Fax Number:
678-888-0642

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4595 TOWNE LAKE PKWY
Provider Second Line Business Practice Location Address:
BLDG 300, SUITE 200
Provider Business Practice Location Address City Name:
WOODSTOCK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30189-5514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-509-0089
Provider Business Practice Location Address Fax Number:
678-888-0642
Provider Enumeration Date:
06/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
SHARON
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
770-509-0089

Provider Taxonomy Codes

  • Taxonomy code: 302F00000X , with the licence number:  030681 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1447206164 . This is a "NPI #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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