1245272541 NPI number — GASTROENTEROLOGY GROUP, LLC

Table of content: (NPI 1245272541)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245272541 NPI number — GASTROENTEROLOGY GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GASTROENTEROLOGY GROUP, 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:
GASTROENTEROLOGY GROUP, A MEDICAL CORPORATION
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:
1245272541
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 848778
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02284-8778
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-871-1721
Provider Business Mailing Address Fax Number:
985-893-6908

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
131 CHEROKEE ROSE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70433-7195
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-871-1721
Provider Business Practice Location Address Fax Number:
985-871-4049
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRAUEN
Authorized Official First Name:
HAZEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
985-871-1721

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CG2313 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 09015774 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: CK5954 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 1799181 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CN9069 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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