Healthcare Provider Details

I. General information

NPI: 1679153407
Provider Name (Legal Business Name): GA GASTRO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4865 BILL GARDNER PKWY
LOCUST GROVE GA
30248-3644
US

IV. Provider business mailing address

1100 HOSPITAL DR STE 200
STOCKBRIDGE GA
30281-6381
US

V. Phone/Fax

Practice location:
  • Phone: 404-641-3345
  • Fax:
Mailing address:
  • Phone: 770-692-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: ARUNA REDDY PRAKASH
Title or Position: ADMINISTRATOR
Credential:
Phone: 404-641-3345