Provider Demographics
NPI:1952778813
Name:MIDDLE GEORGIA COLORECTAL, LLC
Entity Type:Organization
Organization Name:MIDDLE GEORGIA COLORECTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANKUR
Authorized Official - Middle Name:
Authorized Official - Last Name:GOEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-333-5150
Mailing Address - Street 1:109 OSIGIAN BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-8922
Mailing Address - Country:US
Mailing Address - Phone:478-333-5150
Mailing Address - Fax:478-333-5458
Practice Address - Street 1:109 OSIGIAN BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-8922
Practice Address - Country:US
Practice Address - Phone:478-333-5150
Practice Address - Fax:478-333-5458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA073513208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty