Provider Demographics
NPI:1558662858
Name:ATHENS ENDOSCOPY, LLC
Entity Type:Organization
Organization Name:ATHENS ENDOSCOPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TANDEKAH
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-548-0446
Mailing Address - Street 1:21 JEFFERSON PL STE 2
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-1761
Mailing Address - Country:US
Mailing Address - Phone:706-433-0788
Mailing Address - Fax:706-548-4801
Practice Address - Street 1:21 JEFFERSON PL STE 2
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-1761
Practice Address - Country:US
Practice Address - Phone:706-433-0788
Practice Address - Fax:706-433-0786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029-441261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
202G494835Medicare PIN