Healthcare Provider Details

I. General information

NPI: 1265427041
Provider Name (Legal Business Name): GASTROENTEROLOGY CENTER OF WEST GEORGIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 01/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 DOCTORS DR
LAGRANGE GA
30240-4139
US

IV. Provider business mailing address

1551 DOCTORS DR
LAGRANGE GA
30240-4139
US

V. Phone/Fax

Practice location:
  • Phone: 703-684-5771
  • Fax: 706-882-1620
Mailing address:
  • Phone: 706-845-7711
  • Fax: 706-882-1620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: JOHN ROBERT COGGINS VII
Title or Position: PRESIDENT
Credential: M.D.
Phone: 706-845-7711