Provider Demographics
NPI:1114962255
Name:VALDOSTA GASTROENTEROLOGY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:VALDOSTA GASTROENTEROLOGY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:M
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-244-1570
Mailing Address - Street 1:410 CONNELL RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1407
Mailing Address - Country:US
Mailing Address - Phone:229-244-1570
Mailing Address - Fax:229-247-1084
Practice Address - Street 1:410 CONNELL RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1407
Practice Address - Country:US
Practice Address - Phone:229-244-1570
Practice Address - Fax:229-247-1084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300036012AMedicaid
GA300036012AMedicaid