1164609111 NPI number — GASTRO CENTER OF MARYLAND LLC

Table of content: (NPI 1164609111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164609111 NPI number — GASTRO CENTER OF MARYLAND LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GASTRO CENTER OF MARYLAND 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:
MIDATLANTIC CENTER FOR DIGESTIVE & LIVER DIS
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:
1164609111
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7120 MINSTREL WAY
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21045-5248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-290-6677
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7120 MINSTREL WAY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21045-5248
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-290-6677
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RAI
Authorized Official First Name:
RUDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/ PRESIDENT
Authorized Official Telephone Number:
410-290-6677

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  D0044427 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 282701800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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