=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790440204
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GASTRO SOUTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2021
-----------------------------------------------------
Last Update Date | 11/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 240 SHERATON BLVD
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31210-1358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-495-5718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9172 ESTES RD
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31220-5603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-495-5718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | JOEL JUDAH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 706-495-5718
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------