Basic Information
| Provider Information | |||||||||
| NPI: | 1285780692 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED GASTROENTEROLOGY OF MONTEREY COUNTY MEDICAL CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 395 DEL MONTE CENTER STE 173 | ||||||||
| Address2: | |||||||||
| City: | MONTEREY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939406156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8317556352 | ||||||||
| FaxNumber: | 8313721666 | ||||||||
| Practice Location | |||||||||
| Address1: | 1441 CONSTITUTION BLVD | ||||||||
| Address2: | |||||||||
| City: | SALINAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939063100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8317556352 | ||||||||
| FaxNumber: | 8317556297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 02/14/2018 | ||||||||
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| AuthorizedOfficialLastName: | TABBAA | ||||||||
| AuthorizedOfficialFirstName: | MUMTAZ | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8317556352 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | A54688 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 00A546880 | 05 | CA | MEDICAID |