Provider Demographics
NPI:1215986609
Name:SOUTHERN ENDOSCOPY SUITE, LLC
Entity type:Organization
Organization Name:SOUTHERN ENDOSCOPY SUITE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:B
Authorized Official - Last Name:KUKLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO,
Authorized Official - Phone:678-985-2000
Mailing Address - Street 1:763 OLD NORCROSS RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-4317
Mailing Address - Country:US
Mailing Address - Phone:678-985-2000
Mailing Address - Fax:678-985-1999
Practice Address - Street 1:763 OLD NORCROSS RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-4317
Practice Address - Country:US
Practice Address - Phone:678-985-2000
Practice Address - Fax:678-985-1999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA1903X
GA067-200261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00888379AMedicare ID - Type Unspecified