1053431924 NPI number — GASTROENTEROLOGISTS CONSULTANTS OF JASPER, PC

Table of content: (NPI 1053431924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053431924 NPI number — GASTROENTEROLOGISTS CONSULTANTS OF JASPER, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GASTROENTEROLOGISTS CONSULTANTS OF JASPER, PC
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:
GASTROENTEROLOGISTS CONSULTANTS OF JASPER, PC
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:
1053431924
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 391
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JASPER
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35502-0391
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-295-9630
Provider Business Mailing Address Fax Number:
205-295-9362

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3400 HIGHWAY 78 E
Provider Second Line Business Practice Location Address:
MEDICAL ARTS TOWER SUITE 504
Provider Business Practice Location Address City Name:
JASPER
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35501-8907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-295-9630
Provider Business Practice Location Address Fax Number:
205-296-9362
Provider Enumeration Date:
04/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DAVILA
Authorized Official First Name:
LUIS
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
205-295-9630

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  25227 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 051553611DAV , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 515-15424 . This is a "BSBC" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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