Healthcare Provider Details

I. General information

NPI: 1821272345
Provider Name (Legal Business Name): JOHNS CREEK GASTROENTEROLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 12/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 NORTHSIDE FORSYTH DR SUITE 330
CUMMING GA
30041-6020
US

IV. Provider business mailing address

1100 NORTHSIDE FORSYTH DR SUITE 330
CUMMING GA
30041-6020
US

V. Phone/Fax

Practice location:
  • Phone: 770-889-9901
  • Fax: 770-889-9088
Mailing address:
  • Phone: 770-889-9901
  • Fax: 770-889-9088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number035800
License Number StateGA

VIII. Authorized Official

Name: CLIVE ALBERT
Title or Position: OWNER
Credential: M.D.
Phone: 770-889-9901