Provider Demographics
NPI:1831274034
Name:ADVANCED DIGESTIVE CARE CENTER,P.C.
Entity type:Organization
Organization Name:ADVANCED DIGESTIVE CARE CENTER,P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CELESTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAIKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-783-0300
Mailing Address - Street 1:235 MEDICAL BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281
Mailing Address - Country:US
Mailing Address - Phone:678-783-0300
Mailing Address - Fax:678-565-9473
Practice Address - Street 1:235 MEDICAL BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7218
Practice Address - Country:US
Practice Address - Phone:678-783-0300
Practice Address - Fax:678-565-9473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA199807383AMedicaid
GAF11038Medicare UPIN
GA10BDHGVMedicare ID - Type Unspecified