Healthcare Provider Details

I. General information

NPI: 1528192176
Provider Name (Legal Business Name): GASTROENTEROLOGY ASSOCIATES OF CENTRAL GA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 10/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 3RD ST SUITE 206
MACON GA
31201-3294
US

IV. Provider business mailing address

610 3RD ST SUITE 206
MACON GA
31201-3294
US

V. Phone/Fax

Practice location:
  • Phone: 478-464-2600
  • Fax: 478-464-2604
Mailing address:
  • Phone: 478-464-2600
  • Fax: 478-464-2604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. ANGIE CROUCH
Title or Position: ADMINISTRATOR
Credential:
Phone: 478-464-2600