Provider Demographics
NPI:1821106923
Name:ENDOSCOPY CENTER OF COASTAL GEORGIA, LLC
Entity Type:Organization
Organization Name:ENDOSCOPY CENTER OF COASTAL GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-354-9447
Mailing Address - Street 1:519 STEPHENSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-5969
Mailing Address - Country:US
Mailing Address - Phone:912-354-9447
Mailing Address - Fax:912-303-9246
Practice Address - Street 1:519 STEPHENSON AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5969
Practice Address - Country:US
Practice Address - Phone:912-354-9447
Practice Address - Fax:912-303-9246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA86172S261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000969702AMedicaid
GA000969702AMedicaid