Provider Demographics
NPI:1003243072
Name:COLON AND RECTAL CLINIC, LLC
Entity Type:Organization
Organization Name:COLON AND RECTAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KOTA
Authorized Official - Middle Name:R
Authorized Official - Last Name:VENKATESH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-296-5495
Mailing Address - Street 1:3905 JOHNS CREEK COURT SUITE 200
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024
Mailing Address - Country:US
Mailing Address - Phone:770-495-0799
Mailing Address - Fax:770-495-0783
Practice Address - Street 1:3905 JOHNS CREEK CT 200
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1224
Practice Address - Country:US
Practice Address - Phone:770-495-0799
Practice Address - Fax:770-495-0783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-04
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA062621208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA226365641AMedicaid
GA226365641AMedicaid