=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376935023
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GASTROENTEROLOGY & HEPATOLOGY SPECIALISTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2015
-----------------------------------------------------
Last Update Date | 03/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1670 MCKENDREE CHURCH RD #800
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30043-4107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-210-7766
-----------------------------------------------------
Fax | 470-210-7767
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1670 MCKENDREE CHURCH RD #800
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30043-4107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-210-7766
-----------------------------------------------------
Fax | 470-210-7767
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGISTERED AGENT
-----------------------------------------------------
Name | LONG BAO NGUYEN
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 770-557-8788
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 14006863
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------