Healthcare Provider Details

I. General information

NPI: 1952405052
Provider Name (Legal Business Name): SOUTHERN GASTROENTEROLOGY SPECIALISTS, P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 11/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4865 BILL GARDNER PKWY
LOCUST GROVE GA
30248-3644
US

IV. Provider business mailing address

4865 BILL GARDNER PKWY
LOCUST GROVE GA
30248-3644
US

V. Phone/Fax

Practice location:
  • Phone: 770-692-0100
  • Fax:
Mailing address:
  • Phone: 770-692-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ARUNA R PRAKASH
Title or Position: SECRETORY
Credential: B.SC
Phone: 770-692-0100