=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336572049
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACCESS GASTROENTEROLGY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2013
-----------------------------------------------------
Last Update Date | 10/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 FAIR RD SUITE 500
-----------------------------------------------------
City | STATESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-871-3777
-----------------------------------------------------
Fax | 912-871-3677
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1601 FAIR RD SUITE 500
-----------------------------------------------------
City | STATESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-871-3777
-----------------------------------------------------
Fax | 912-871-3677
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYISICAN
-----------------------------------------------------
Name | DR. PATRICK DORVILUS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 912-871-3777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 060450
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------