Healthcare Provider Details

I. General information

NPI: 1548206493
Provider Name (Legal Business Name): NORTHERN CRESCENT ENDOSCOPY SUITE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 08/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5671 PEACHTREE DUNWOODY RD NE SUITE 680
ATLANTA GA
30342-5000
US

IV. Provider business mailing address

550 PEACHTREE ST NE SUITE 1600
ATLANTA GA
30308-2208
US

V. Phone/Fax

Practice location:
  • Phone: 404-705-6985
  • Fax: 404-851-9950
Mailing address:
  • Phone: 404-888-7575
  • Fax: 404-885-7777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JANA BAKER
Title or Position: ADMINISTRATOR
Credential:
Phone: 404-888-7575