1366687147 NPI number — PEDIATRIC GASTROENTEROLOGY ASSOCIATES OF SOUTHERN CALIFORNIA

Table of content: (NPI 1366687147)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366687147 NPI number — PEDIATRIC GASTROENTEROLOGY ASSOCIATES OF SOUTHERN CALIFORNIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC GASTROENTEROLOGY ASSOCIATES OF SOUTHERN CALIFORNIA
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:
1366687147
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 61566
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92602-6052
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-933-3009
Provider Business Mailing Address Fax Number:
562-933-8557

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1760 TERMINO AVE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90804-2105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-933-3009
Provider Business Practice Location Address Fax Number:
562-933-8557
Provider Enumeration Date:
12/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
STEINMETZ
Authorized Official First Name:
BARRY
Authorized Official Middle Name:
ARTHUR
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
562-933-3009

Provider Taxonomy Codes

  • Taxonomy code: 2080P0206X , with the licence number:  A68880 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1731638 . This is a "GROUP MEDICAL PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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