Provider Demographics
NPI:1073587523
Name:CAPITAL CITY GASTROENTEROLOGY, PC
Entity Type:Organization
Organization Name:CAPITAL CITY GASTROENTEROLOGY, PC
Other - Org Name:CAPITAL CITY GATSROENTEROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-239-9257
Mailing Address - Street 1:4126 CARMICHAEL CT
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-2871
Mailing Address - Country:US
Mailing Address - Phone:334-495-2600
Mailing Address - Fax:334-495-2604
Practice Address - Street 1:4126 CARMICHAEL CT
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2871
Practice Address - Country:US
Practice Address - Phone:334-495-2600
Practice Address - Fax:334-495-2604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-13
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
01D1026965OtherCLIA WAIVER