1235246240 NPI number — PREMIER GASTROENTEROLOGY PA

Table of content: (NPI 1235246240)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235246240 NPI number — PREMIER GASTROENTEROLOGY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER GASTROENTEROLOGY PA
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:
6
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:
1235246240
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12102 CORTEZ BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKSVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34613-5514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-597-4000
Provider Business Mailing Address Fax Number:
352-597-0550

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12102 CORTEZ BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKSVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34613-5514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-597-4000
Provider Business Practice Location Address Fax Number:
352-597-0550
Provider Enumeration Date:
08/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HIBA
Authorized Official First Name:
MUHAMMED-RODWAN
Authorized Official Middle Name:
ALI
Authorized Official Title or Position:
OWNER/CEO
Authorized Official Telephone Number:
352-597-4000

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  ME69833 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100016261 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2987121 . This is a "UHC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 360846358 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2593473 . This is a "GHI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7130182 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2119601215701 . This is a "BEECH ST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1003105 . This is a "HUMANA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2579162-0 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 49489 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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