Basic Information
| Provider Information | |||||||||
| NPI: | 1508861139 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GASTRO EAST PHYSICIANS, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3950 KRESGE WAY | ||||||||
| Address2: | STE 207 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028930220 | ||||||||
| FaxNumber: | 5028930563 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 KRESGE WAY | ||||||||
| Address2: | STE 207 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028930220 | ||||||||
| FaxNumber: | 5028930563 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HEINE | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5028930220 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 174400000X | 207RG0100X | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 65938243 | 05 | KY | MEDICAID |