=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871529529
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GASTROENTEROLOGY OF NORTHEAST GEORGIA PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2006
-----------------------------------------------------
Last Update Date | 05/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35 HOSPITAL RD
-----------------------------------------------------
City | BLAIRSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30512-3139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-745-8800
-----------------------------------------------------
Fax | 706-745-8805
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 759
-----------------------------------------------------
City | BLAIRSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30514-0759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-745-8800
-----------------------------------------------------
Fax | 706-745-8805
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. SCOTT W AINSWORTH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 706-745-8800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------