Provider Demographics
NPI:1790440204
Name:GASTRO SOUTH, LLC
Entity Type:Organization
Organization Name:GASTRO SOUTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JUDAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-495-5718
Mailing Address - Street 1:9172 ESTES RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31220-5603
Mailing Address - Country:US
Mailing Address - Phone:706-495-5718
Mailing Address - Fax:
Practice Address - Street 1:240 SHERATON BLVD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1358
Practice Address - Country:US
Practice Address - Phone:706-495-5718
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty