Provider Demographics
NPI:1669533568
Name:ATLANTA SOUTH ENDOSCOPY CENTER LLC
Entity type:Organization
Organization Name:ATLANTA SOUTH ENDOSCOPY CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-888-7575
Mailing Address - Street 1:34 UPPER RIVERDALE RD SE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2635
Mailing Address - Country:US
Mailing Address - Phone:678-904-9710
Mailing Address - Fax:678-904-9712
Practice Address - Street 1:34 UPPER RIVERDALE RD SE
Practice Address - Street 2:SUITE 201
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2635
Practice Address - Country:US
Practice Address - Phone:678-904-9710
Practice Address - Fax:678-904-9712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA111267ASCAMedicare ID - Type Unspecified