1689789760 NPI number — GASTROENTEROLOGY AND ENDOSCOPY ASSOCIATES OF FORT WORTH, P.A.

Table of content: (NPI 1689789760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689789760 NPI number — GASTROENTEROLOGY AND ENDOSCOPY ASSOCIATES OF FORT WORTH, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GASTROENTEROLOGY AND ENDOSCOPY ASSOCIATES OF FORT WORTH, P.A.
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:
1689789760
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6300 RIDGLEA PL STE 1103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76116-5737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-926-9087
Provider Business Mailing Address Fax Number:
817-924-1268

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6300 RIDGLEA PL STE 1103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76116-5737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-926-9087
Provider Business Practice Location Address Fax Number:
817-924-1268
Provider Enumeration Date:
08/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KASAL
Authorized Official First Name:
NATARAJ
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
817-926-9087

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  E5808 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CD3144 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0856858-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4037687 . This is a "AETNA PROV ID #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".