MEDICARE: GASTROINTESTINAL DIAGNOSTIC ENDOSCOPY WOODSTOCK, 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	261QE0800X	Endoscopy Clinic/Center
2	261QA1903X	Ambulatory Surgical Clinic/Center	028-451	GA

General Provider Information

NPI Number	:	1760778765
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GASTROINTESTINAL DIAGNOSTIC ENDOSCOPY WOODSTOCK, LLC

Provider Business Mailing Address
First Line	:	2550 WINDY HILL RD SE STE 302
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30067-8655
Country	:	US
Telephone Number	:	678-741-5000
Fax Number	:	678-741-2301

Provider Business Practice Location Address
First Line	:	118 MILL ST STE 100
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30188-4880
Country	:	US
Telephone Number	:	770-226-9070
Fax Number	:	770-226-8863

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATION
Name	:	TRACY L JONES
Credential	:
Telephone Number	:	678-741-2317

Provider Enumeration Date	:	06/28/2011
Last Update Date	:	12/03/2025

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