Healthcare Provider Details

I. General information

NPI: 1609940352
Provider Name (Legal Business Name): MARLBORO GASTROENTEROLOGY ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 ENDO LN SUITE 1
HAMLET NC
28345-4560
US

IV. Provider business mailing address

PO BOX 617
BENNETTSVILLE SC
29512-0617
US

V. Phone/Fax

Practice location:
  • Phone: 910-582-3636
  • Fax: 910-205-2251
Mailing address:
  • Phone: 843-479-9794
  • Fax: 843-479-8076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License NumberAS0083
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberAS0083
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3409943
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 2
IdentifierP00364907
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerRR MEDICARE

VIII. Authorized Official

Name: MRS. PATRICIA J RIDDLE
Title or Position: ADMINISTRATOR
Credential:
Phone: 843-479-9794