Provider Demographics
NPI:1760778765
Name:GASTROINTESTINAL DIAGNOSTIC ENDOSCOPY WOODSTOCK, LLC
Entity Type:Organization
Organization Name:GASTROINTESTINAL DIAGNOSTIC ENDOSCOPY WOODSTOCK, LLC
Other - Org Name:TOWN LAKE ENDOSCOPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORA
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-741-2317
Mailing Address - Street 1:2550 WINDY HILL RD SE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8665
Mailing Address - Country:US
Mailing Address - Phone:678-741-5000
Mailing Address - Fax:678-741-2301
Practice Address - Street 1:118 MILL ST
Practice Address - Street 2:SUITE 100
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-4879
Practice Address - Country:US
Practice Address - Phone:770-226-9070
Practice Address - Fax:770-226-8863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-28
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028-451261QA1903X
261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G497327Medicare UPIN
GA11C0001379Medicare Oscar/Certification