1598772188 NPI number — NACOGDOCHES GASTROENTEROLOGY, P.A.

Table of content: (NPI 1598772188)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598772188 NPI number — NACOGDOCHES GASTROENTEROLOGY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NACOGDOCHES GASTROENTEROLOGY, 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:
MICHAEL E. MOLLOT, M.D.
Provider Other Organization Name Type Code:
5
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:
1598772188
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1018 N MOUND ST
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
NACOGDOCHES
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75961-4492
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-569-6449
Provider Business Mailing Address Fax Number:
936-569-2458

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1018 N MOUND ST
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
NACOGDOCHES
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75961-4492
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-569-6449
Provider Business Practice Location Address Fax Number:
936-569-2458
Provider Enumeration Date:
08/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRIFFIN
Authorized Official First Name:
JILL
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
936-569-6449

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  J3164 , 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)





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