Provider Demographics
NPI:1386670404
Name:ADVANCED GASTROENTEROLOGY GROUP
Entity Type:Organization
Organization Name:ADVANCED GASTROENTEROLOGY GROUP
Other - Org Name:ADVANCED GASTROENTEROLOGY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-509-0089
Mailing Address - Street 1:4595 TOWNE LAKE PKWY
Mailing Address - Street 2:BLDG 300, SUITE 200
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-5514
Mailing Address - Country:US
Mailing Address - Phone:770-509-0089
Mailing Address - Fax:678-888-0642
Practice Address - Street 1:4595 TOWNE LAKE PKWY
Practice Address - Street 2:BLDG 300, SUITE 200
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-5514
Practice Address - Country:US
Practice Address - Phone:770-509-0089
Practice Address - Fax:678-888-0642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030681302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1447206164OtherNPI #
GA1447206164OtherNPI #