Basic Information
| Provider Information | |||||||||
| NPI: | 1447234919 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENGASTRO LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ENDOSCOPY CENTER FOR DIGESTIVE HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 53RD AVE | ||||||||
| Address2: | |||||||||
| City: | BETTENDORF | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527227546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633832686 | ||||||||
| FaxNumber: | 5638848144 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 53RD AVE | ||||||||
| Address2: | |||||||||
| City: | BETTENDORF | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527227546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633832686 | ||||||||
| FaxNumber: | 5638848144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 10/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TAGUE | ||||||||
| AuthorizedOfficialFirstName: | PAIGE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | LEAD INSURANCE BILLER | ||||||||
| AuthorizedOfficialTelephone: | 5633832686 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | IA | N | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy | 261QA1903X | IA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | BG865037 | 01 | DEA | OTHER | 1603165 | 01 | IA | CSA | OTHER | 0610279 | 05 | IA | MEDICAID |