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General NPI Number Information
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NPI Number | 1003243072
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Entity Type | Organization
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Legal Business Name | COLON AND RECTAL CLINIC, LLC
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Dates
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Enumeration Date | 10/04/2013
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Last Update Date | 06/26/2023
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Provider Practice Location Address
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Address Line | 3905 JOHNS CREEK CT 200
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City | SUWANEE
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State | GA
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Zip | 30024-1224
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Country | US
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Telephone | 770-495-0799
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Fax | 770-495-0783
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Provider Business Mailing Address
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Address Line | 3905 JOHNS CREEK COURT SUITE 200
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City | SUWANEE
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State | GA
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Zip | 30024
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Country | US
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Telephone | 770-495-0799
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Fax | 770-495-0783
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Authorized Official
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Title or Position | OWNER
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Name | KOTA R VENKATESH
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Credential | M.D.
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Telephone | 678-296-5495
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208C00000X
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Taxonomy Name | Colon & Rectal Surgery Physician
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License Number | 062621
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License Number State | GA
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