Healthcare Provider Details

I. General information

NPI: 1831134121
Provider Name (Legal Business Name): VALDOSTA ENDOSCOPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 06/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 CONNELL RD
VALDOSTA GA
31602-1407
US

IV. Provider business mailing address

410 CONNELL RD
VALDOSTA GA
31602-1407
US

V. Phone/Fax

Practice location:
  • Phone: 229-244-1570
  • Fax: 229-247-1084
Mailing address:
  • Phone: 229-244-1570
  • Fax: 229-247-1084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number092-243
License Number StateGA

VIII. Authorized Official

Name: DR. ERIC M WARD
Title or Position: PHYSICIAN
Credential: MD
Phone: 229-244-1570