Basic Information
| Provider Information | |||||||||
| NPI: | 1003880279 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED GASTRO & LIVER CARE PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 20267 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336220267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278232188 | ||||||||
| FaxNumber: | 7278280823 | ||||||||
| Practice Location | |||||||||
| Address1: | 6225 66TH ST N | ||||||||
| Address2: | |||||||||
| City: | PINELLAS PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337815025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275210994 | ||||||||
| FaxNumber: | 7275222671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 02/23/2010 | ||||||||
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| AuthorizedOfficialLastName: | GLAMOUR | ||||||||
| AuthorizedOfficialFirstName: | TEJUNDER | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7275210994 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0008X | ME68156 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hepatology | 207RG0100X | ME68156 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 34875 | 01 | BCBS - GROUP # | OTHER | 34875 | 01 | MCR - GROUP # | OTHER | 268039400 | 01 | MCD | OTHER | DA8281 | 01 | MCR RR | OTHER |