Provider Demographics
NPI:1922054410
Name:BRUNSWICK ENDOSCOPY CENTER, LLC
Entity Type:Organization
Organization Name:BRUNSWICK ENDOSCOPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RITA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:912-267-1802
Mailing Address - Street 1:3217 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-3759
Mailing Address - Country:US
Mailing Address - Phone:912-267-1802
Mailing Address - Fax:912-267-0061
Practice Address - Street 1:3217 4TH ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-3759
Practice Address - Country:US
Practice Address - Phone:912-267-1802
Practice Address - Fax:912-267-0061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA063-134261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00763639AMedicaid
GA111135ASCAMedicare PIN
GA00763639AMedicaid