Provider Demographics
NPI:1043411648
Name:COFFEE COUNTY CENTER FOR DIGESTIVE DISEASES LLC
Entity Type:Organization
Organization Name:COFFEE COUNTY CENTER FOR DIGESTIVE DISEASES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SUDHAKAR
Authorized Official - Middle Name:
Authorized Official - Last Name:JONNALAGADDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-384-7276
Mailing Address - Street 1:300 SHIRLEY AVENUE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533
Mailing Address - Country:US
Mailing Address - Phone:912-384-7276
Mailing Address - Fax:912-384-4353
Practice Address - Street 1:300 SHIRLEY AVENUE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533
Practice Address - Country:US
Practice Address - Phone:912-384-7276
Practice Address - Fax:912-384-4353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034-295261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA034-295OtherSTATE PERMIT
GA474131643AMedicaid
GA111246ASCAMedicare PIN