Provider Demographics
NPI:1285925941
Name:CENTRAL GEORGIA GASTROENTEROLOGY, LLC
Entity type:Organization
Organization Name:CENTRAL GEORGIA GASTROENTEROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-474-1769
Mailing Address - Street 1:791 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:791 POPLAR ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2045
Practice Address - Country:US
Practice Address - Phone:478-474-1769
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-28
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037564174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF65259Medicare UPIN