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General NPI Number Information
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NPI Number | 1366625535
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Entity Type | Organization
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Legal Business Name | GASTROENTEROLOGY MEDICINE & NUTRITION CLINIC, PC
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Dates
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Enumeration Date | 12/11/2007
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Last Update Date | 06/12/2025
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Provider Practice Location Address
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Address Line | 3886 PRINCETON LAKES WAY SW STE 120
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City | ATLANTA
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State | GA
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Zip | 30331-5511
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Country | US
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Telephone | 404-681-0000
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Fax | 678-866-2538
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Provider Business Mailing Address
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Address Line | PO BOX 570744
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City | ATLANTA
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State | GA
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Zip | 30357-3113
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Country | US
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Telephone | 404-681-0000
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Fax | 404-365-8354
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. EDWARD A LAYNE
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Credential | M.D.
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Telephone | 404-681-0000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 021539
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 021539
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License Number State | GA
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