Provider Demographics
NPI:1366634669
Name:GASTROINTESTINAL ASSOCIATES ENDOSCOPY CENTER, LLC
Entity Type:Organization
Organization Name:GASTROINTESTINAL ASSOCIATES ENDOSCOPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:PIERCE
Authorized Official - Middle Name:D
Authorized Official - Last Name:DOTHEROW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-355-1234
Mailing Address - Street 1:2510 LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9513
Mailing Address - Country:US
Mailing Address - Phone:601-355-1234
Mailing Address - Fax:601-326-3566
Practice Address - Street 1:1815 MISSION 66
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3709
Practice Address - Country:US
Practice Address - Phone:601-355-1234
Practice Address - Fax:601-326-3566
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GASTROINTESTINAL ASSOCIATES ENDOSCOPY CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-10
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS25C0001065261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04837303Medicaid
MS472880Medicare PIN
MS04837303Medicaid