MEDICARE: GASTROENTEROLOGY PHYSICIAN SERVICES LLC

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
1	2080P0206X	Pediatric Gastroenterology Physician
2	207RG0100X	Gastroenterology Physician

General Provider Information

NPI Number	:	1750025425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GASTROENTEROLOGY PHYSICIAN SERVICES LLC

Provider Business Mailing Address
First Line	:	PO BOX 8629
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31908-8629
Country	:	US
Telephone Number	:	706-655-8800
Fax Number	:	706-940-4764

Provider Business Practice Location Address
First Line	:	2200 HAMILTON RD
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31904-8855
Country	:	US
Telephone Number	:	706-655-8800
Fax Number	:	706-940-4764

Authorized Official
Title or Position	:	CEO
Name	:	SHANE B DARRAH
Credential	:	MD
Telephone Number	:	706-243-4500

Provider Enumeration Date	:	04/27/2022
Last Update Date	:	06/06/2022

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