1154363893 NPI number — SOUTHWEST GASTROENTEROLOGY ASSOCIATES, INC

Table of content: (NPI 1154363893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154363893 NPI number — SOUTHWEST GASTROENTEROLOGY ASSOCIATES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST GASTROENTEROLOGY ASSOCIATES, INC
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:
OUTHWEST GASTROENTEROLOGY ASSOCIATES
Provider Other Organization Name Type Code:
4
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:
1154363893
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
80 LANDINGS DR STE 205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15301-9408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-941-3020
Provider Business Mailing Address Fax Number:
724-426-7713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
80 LANDINGS DR STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15301-9408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-941-3020
Provider Business Practice Location Address Fax Number:
724-426-7713
Provider Enumeration Date:
06/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PANICCO
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
724-941-3020

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0006800690002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com