Provider Demographics
NPI:1821272345
Name:JOHNS CREEK GASTROENTEROLOGY PC
Entity Type:Organization
Organization Name:JOHNS CREEK GASTROENTEROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLIVE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-889-9901
Mailing Address - Street 1:1100 NORTHSIDE FORSYTH DR
Mailing Address - Street 2:SUITE 330
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-6020
Mailing Address - Country:US
Mailing Address - Phone:770-889-9901
Mailing Address - Fax:770-889-9088
Practice Address - Street 1:1100 NORTHSIDE FORSYTH DR
Practice Address - Street 2:SUITE 330
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-6020
Practice Address - Country:US
Practice Address - Phone:770-889-9901
Practice Address - Fax:770-889-9088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035800207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6732Medicare PIN