Provider Demographics
NPI:1548206493
Name:NORTHERN CRESCENT ENDOSCOPY SUITE, LLC
Entity Type:Organization
Organization Name:NORTHERN CRESCENT ENDOSCOPY SUITE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-888-7575
Mailing Address - Street 1:550 PEACHTREE ST NE
Mailing Address - Street 2:SUITE 1600
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2208
Mailing Address - Country:US
Mailing Address - Phone:404-888-7575
Mailing Address - Fax:404-885-7777
Practice Address - Street 1:5671 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 680
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-5000
Practice Address - Country:US
Practice Address - Phone:404-705-6985
Practice Address - Fax:404-851-9950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA543655296AMedicaid
GA111158ASCAMedicare ID - Type Unspecified
GA543655296AMedicaid