Healthcare Provider Details

I. General information

NPI: 1750025425
Provider Name (Legal Business Name): GASTROENTEROLOGY PHYSICIAN SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 06/06/2022
Certification Date: 06/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 HAMILTON RD
COLUMBUS GA
31904-8855
US

IV. Provider business mailing address

PO BOX 8629
COLUMBUS GA
31908-8629
US

V. Phone/Fax

Practice location:
  • Phone: 706-655-8800
  • Fax: 706-940-4764
Mailing address:
  • Phone: 706-655-8800
  • Fax: 706-940-4764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: SHANE B DARRAH
Title or Position: CEO
Credential: MD
Phone: 706-243-4500