Provider Demographics
NPI:1518009430
Name:WELLBROOK ENDOSCOPY CENTER, LLC
Entity Type:Organization
Organization Name:WELLBROOK ENDOSCOPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARCZUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-625-5132
Mailing Address - Street 1:7229 WHEAT ST NE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-1566
Mailing Address - Country:US
Mailing Address - Phone:678-625-5132
Mailing Address - Fax:678-625-5137
Practice Address - Street 1:1269 WELLBROOK CIR NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3873
Practice Address - Country:US
Practice Address - Phone:770-922-0505
Practice Address - Fax:678-625-5137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4034261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA111103ASCAMedicare PIN
GA252884128AMedicare PIN
GA10BBBWGMedicare PIN
GA00750285AMedicaid
GA511I100001Medicare PIN
GA10BBCKZMedicare PIN
GA111103ASCAMedicare PIN