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NPI Code Detail

MEDICARE: GASTROINTESTINAL ENDOSCOPY OF GWINNETT, P.C.

MEDICARE: GASTROINTESTINAL ENDOSCOPY OF GWINNETT, P.C.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QA1903XAmbulatory Surgical Clinic/Center111072GA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
24103OTHERGABLUE CROSS BLUE SHIELD

General Provider Information

NPI Number : 1699769703
Entity Type Code : Organization
Provider Name (Legal Business Name) : GASTROINTESTINAL ENDOSCOPY OF GWINNETT, P.C.
Provider Business Mailing Address
First Line : 600 PROFESSIONAL DR
Second Line : STE 130
City : LAWRENCEVILLE
State : GA
Zip : 30045-7651
Country : US
Telephone Number : 770-995-7989
Fax Number : 770-339-8646
Provider Business Practice Location Address
First Line : 600 PROFESSIONAL DR
Second Line : STE 130
City : LAWRENCEVILLE
State : GA
Zip : 30045-7651
Country : US
Telephone Number : 770-995-7989
Fax Number : 770-339-8646
Authorized Official
Title or Position : PRESIDENT CEO
Name : DR. ZACK ZEKE MARTIN
Credential :
Telephone Number : 770-995-7989
Provider Enumeration Date : 09/02/2005
Last Update Date : 08/22/2020

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