Provider Demographics
NPI:1487647483
Name:WESTSIDE ENDOSCOPY CENTER PC
Entity Type:Organization
Organization Name:WESTSIDE ENDOSCOPY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEVON
Authorized Official - Middle Name:
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-941-4810
Mailing Address - Street 1:3825 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1109
Mailing Address - Country:US
Mailing Address - Phone:678-945-9600
Mailing Address - Fax:770-948-9149
Practice Address - Street 1:3825 MEDICAL PARK DR
Practice Address - Street 2:SUITE 300
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1109
Practice Address - Country:US
Practice Address - Phone:678-945-9600
Practice Address - Fax:770-948-9149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2024-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033269261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA111230ASCAMedicare ID - Type Unspecified