Provider Demographics
NPI:1891737532
Name:GASTROENTEROLOGY ATLANTA, LLC
Entity Type:Organization
Organization Name:GASTROENTEROLOGY ATLANTA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:LYDAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-400-6041
Mailing Address - Street 1:3025 BRECKINRIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4979
Mailing Address - Country:US
Mailing Address - Phone:678-226-0082
Mailing Address - Fax:
Practice Address - Street 1:2006 MACY DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-6346
Practice Address - Country:US
Practice Address - Phone:404-257-0000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008698207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CG3056Medicare PIN
GAGRP3584Medicare PIN