Provider Demographics
NPI:1811052749
Name:GDC ENDOSCOPY CENTER LLC
Entity type:Organization
Organization Name:GDC ENDOSCOPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BHUVANENDRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:INDRAKRISHNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-377-8252
Mailing Address - Street 1:475 PHILIP BLVD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-8737
Mailing Address - Country:US
Mailing Address - Phone:678-377-8252
Mailing Address - Fax:770-963-0122
Practice Address - Street 1:2887 DARLINGTON RUN
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-4315
Practice Address - Country:US
Practice Address - Phone:678-377-8252
Practice Address - Fax:770-963-0122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11C0001280261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA839960927AMedicaid
GA1598847618OtherNPI
GA1598847618OtherNPI
GA111280ASCAMedicare ID - Type UnspecifiedMEDICARE ID#