Provider Demographics
NPI:1609940352
Name:MARLBORO GASTROENTEROLOGY ASSOCIATES PA
Entity Type:Organization
Organization Name:MARLBORO GASTROENTEROLOGY ASSOCIATES PA
Other - Org Name:MARLBORO GI ENDOSCOPY CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:RIDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-479-9794
Mailing Address - Street 1:PO BOX 617
Mailing Address - Street 2:
Mailing Address - City:BENNETTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29512-0617
Mailing Address - Country:US
Mailing Address - Phone:843-479-9794
Mailing Address - Fax:843-479-8076
Practice Address - Street 1:102 ENDO LN
Practice Address - Street 2:SUITE 1
Practice Address - City:HAMLET
Practice Address - State:NC
Practice Address - Zip Code:28345-4560
Practice Address - Country:US
Practice Address - Phone:910-582-3636
Practice Address - Fax:910-205-2251
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARLBORO GASTROENTEROLOGY ASSOCIATES PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCAS0083261QA1903X, 261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409943Medicaid
NCP00364907OtherRR MEDICARE
NCP00364907OtherRR MEDICARE