Provider Demographics
NPI:1578531208
Name:NORTHEAST ENDOSCOPY CENTER, LLC
Entity Type:Organization
Organization Name:NORTHEAST ENDOSCOPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:678-879-0999
Mailing Address - Street 1:721 WELLNESS WAY
Mailing Address - Street 2:STE 110
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3304
Mailing Address - Country:US
Mailing Address - Phone:678-879-0999
Mailing Address - Fax:678-879-0109
Practice Address - Street 1:721 WELLNESS WAY
Practice Address - Street 2:STE 110
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3304
Practice Address - Country:US
Practice Address - Phone:678-879-0999
Practice Address - Fax:678-578-6873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-09
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067329261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA111276ASCAMedicare ID - Type Unspecified