Healthcare Provider Details

I. General information

NPI: 1366625535
Provider Name (Legal Business Name): GASTROENTEROLOGY MEDICINE & NUTRITION CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3886 PRINCETON LAKES WAY SW STE 120
ATLANTA GA
30331-5511
US

IV. Provider business mailing address

PO BOX 570744
ATLANTA GA
30357-3113
US

V. Phone/Fax

Practice location:
  • Phone: 404-681-0000
  • Fax: 678-866-2538
Mailing address:
  • Phone: 404-681-0000
  • Fax: 404-365-8354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number021539
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number021539
License Number StateGA

VIII. Authorized Official

Name: DR. EDWARD A LAYNE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 404-681-0000