Provider Demographics
NPI:1699769703
Name:GASTROINTESTINAL ENDOSCOPY OF GWINNETT, P.C.
Entity type:Organization
Organization Name:GASTROINTESTINAL ENDOSCOPY OF GWINNETT, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ZACK
Authorized Official - Middle Name:ZEKE
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-995-7989
Mailing Address - Street 1:600 PROFESSIONAL DR
Mailing Address - Street 2:STE 130
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-7651
Mailing Address - Country:US
Mailing Address - Phone:770-995-7989
Mailing Address - Fax:770-339-8646
Practice Address - Street 1:600 PROFESSIONAL DR
Practice Address - Street 2:STE 130
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-7651
Practice Address - Country:US
Practice Address - Phone:770-995-7989
Practice Address - Fax:770-339-8646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA111072261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00643365AMedicaid
GA4103OtherBLUE CROSS BLUE SHIELD
GA00643365AMedicaid