Provider Demographics
NPI:1841460490
Name:SOUTH ATLANTA DIGESTIVE DISEASES ASSOCIATES
Entity type:Organization
Organization Name:SOUTH ATLANTA DIGESTIVE DISEASES ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE AMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PETRONILLA
Authorized Official - Middle Name:C
Authorized Official - Last Name:OKERE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-761-7949
Mailing Address - Street 1:1151 CLEVELAND AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-3600
Mailing Address - Country:US
Mailing Address - Phone:404-761-7949
Mailing Address - Fax:404-761-7386
Practice Address - Street 1:1151 CLEVELAND AVE
Practice Address - Street 2:SUITE D
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3600
Practice Address - Country:US
Practice Address - Phone:404-761-7949
Practice Address - Fax:404-761-7386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048686207R00000X, 207RI0008X, 207RT0003X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatologyGroup - Single Specialty
No207RT0003XAllopathic & Osteopathic PhysiciansInternal MedicineTransplant HepatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000893483CMedicaid
GA003089OtherBCBS
GAG53775Medicare UPIN
GAGRP6178Medicare PIN