1154304087 NPI number — GASTROENTEROLOGY ASSOCIATES OF SOUTHWEST FLORIDA LLC

Table of content: (NPI 1154304087)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154304087 NPI number — GASTROENTEROLOGY ASSOCIATES OF SOUTHWEST FLORIDA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GASTROENTEROLOGY ASSOCIATES OF SOUTHWEST FLORIDA LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154304087
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4790 BARKLEY CIR
Provider Second Line Business Mailing Address:
BUILDING A
Provider Business Mailing Address City Name:
FT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33907-7543
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-275-8882
Provider Business Mailing Address Fax Number:
239-275-6304

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4790 BARKLEY CIR
Provider Second Line Business Practice Location Address:
BUILDING A
Provider Business Practice Location Address City Name:
FT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33907-7543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-275-8882
Provider Business Practice Location Address Fax Number:
239-275-6304
Provider Enumeration Date:
11/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SHARMA
Authorized Official First Name:
NEEKAYTAN
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
239-275-8882

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 370377100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: CL0683 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2400027 . This is a "GHI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 8720453 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 39058 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 116848900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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