Healthcare Provider Details

I. General information

NPI: 1265618904
Provider Name (Legal Business Name): JACKSON GASTROENTEROLOGY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2008
Last Update Date: 10/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 ANN ARBOR ROAD
JACKSON MI
49202
US

IV. Provider business mailing address

4400 ANN ARBOR ROAD
JACKSON MI
49202
US

V. Phone/Fax

Practice location:
  • Phone: 517-990-0602
  • Fax:
Mailing address:
  • Phone: 517-990-0602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateMI

VIII. Authorized Official

Name: MR. RODNEY LUNN
Title or Position: MEMBER
Credential:
Phone: 615-425-0818