Basic Information
| Provider Information | |||||||||
| NPI: | 1083851042 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED GASTROENTEROLOGY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3276 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477313276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124730181 | ||||||||
| FaxNumber: | 8124735822 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 S 7TH ST STE SB406 | ||||||||
| Address2: | |||||||||
| City: | VINCENNES | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475911038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128858770 | ||||||||
| FaxNumber: | 8128858771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2009 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | SANDY | ||||||||
| AuthorizedOfficialFirstName: | REGINALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8128858770 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207RG0100X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.