Provider Demographics
NPI:1922077403
Name:MARLBORO GASTROENTEROLOGY ASSOCIATES PA
Entity Type:Organization
Organization Name:MARLBORO GASTROENTEROLOGY ASSOCIATES PA
Other - Org Name:MARLBORO GI ENDOSCOPY CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MGR ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:RIDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-479-9794
Mailing Address - Street 1:PO BOX 617
Mailing Address - Street 2:
Mailing Address - City:BENNETTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29512-0617
Mailing Address - Country:US
Mailing Address - Phone:843-479-6268
Mailing Address - Fax:843-479-8076
Practice Address - Street 1:102 ENDO LN
Practice Address - Street 2:
Practice Address - City:HAMLET
Practice Address - State:NC
Practice Address - Zip Code:28345-4560
Practice Address - Country:US
Practice Address - Phone:910-205-3035
Practice Address - Fax:910-205-3062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10779207RG0100X
NC27767207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0191FOtherBCBS GROUP
SCPC1896Medicaid
SCDE8861OtherSC RR MEDICARE GROUP
NC890191FMedicaid
NCCF8544OtherRR MEDICARE
NC0191FOtherBCBS GROUP
NCCF8544OtherRR MEDICARE