Basic Information
| Provider Information | |||||||||
| NPI: | 1255717641 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST PETERSBURG GASTROENTEROLOGY ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2763 1ST AVE N | ||||||||
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| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337138723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278201039 | ||||||||
| FaxNumber: | 7278228081 | ||||||||
| Practice Location | |||||||||
| Address1: | 1839 CENTRAL AVE | ||||||||
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| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337138900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278201040 | ||||||||
| FaxNumber: | 7278228081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2015 | ||||||||
| LastUpdateDate: | 10/12/2015 | ||||||||
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| AuthorizedOfficialLastName: | AYYUB | ||||||||
| AuthorizedOfficialFirstName: | ELIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SOLE MBR | ||||||||
| AuthorizedOfficialTelephone: | 7273221054 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | OS10833 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.