Provider Demographics
NPI:1043547912
Name:ATLANTA GASTROENTEROLOGY SPECIALISTS, PC
Entity Type:Organization
Organization Name:ATLANTA GASTROENTEROLOGY SPECIALISTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:SALZBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-957-0057
Mailing Address - Street 1:4395 JOHNS CREEK PKWY STE 130
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6125
Mailing Address - Country:US
Mailing Address - Phone:678-957-0057
Mailing Address - Fax:678-957-0047
Practice Address - Street 1:4395 JOHNS CREEK PKWY STE 130
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6125
Practice Address - Country:US
Practice Address - Phone:678-357-0057
Practice Address - Fax:678-382-6406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-12
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029775207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003198458AMedicaid
GA000424476FMedicaid