Provider Demographics
NPI:1366625535
Name:GASTROENTEROLOGY MEDICINE & NUTRITION CLINIC, PC
Entity Type:Organization
Organization Name:GASTROENTEROLOGY MEDICINE & NUTRITION CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-681-0000
Mailing Address - Street 1:PO BOX 77007
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30357-1007
Mailing Address - Country:US
Mailing Address - Phone:404-681-0000
Mailing Address - Fax:404-365-8354
Practice Address - Street 1:3200 DOWNWOOD CIR NW STE 340
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-1605
Practice Address - Country:US
Practice Address - Phone:404-681-0000
Practice Address - Fax:404-365-8354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021539207RG0100X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00204586BMedicaid
GAD30027Medicare UPIN
GA10BBCDLMedicare PIN