Healthcare Provider Details

I. General information

NPI: 1558553859
Provider Name (Legal Business Name): GASTROINTESTINAL ASSOCIATES ENDOSCOPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2007
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 HIGHLAND WAY STE 101
MADISON MS
39110-6930
US

IV. Provider business mailing address

2510 LAKELAND DR
FLOWOOD MS
39232-9513
US

V. Phone/Fax

Practice location:
  • Phone: 601-355-1234
  • Fax: 601-326-3566
Mailing address:
  • Phone: 601-355-1234
  • Fax: 601-326-3566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number25C0001070
License Number StateMS

VIII. Authorized Official

Name: PIERCE D DOTHEROW
Title or Position: AUTHORIZED OFFICIAL
Credential: M.D.
Phone: 601-355-1234