Basic Information
| Provider Information | |||||||||
| NPI: | 1528122827 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GASTROENTEROLOGY CONSULTANTS OF CLEARWATER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 508 JEFFORDS ST STE D | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337563839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274437700 | ||||||||
| FaxNumber: | 7274437701 | ||||||||
| Practice Location | |||||||||
| Address1: | 508 JEFFORDS STREET STE D | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274437700 | ||||||||
| FaxNumber: | 7274437701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2006 | ||||||||
| LastUpdateDate: | 12/08/2011 | ||||||||
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| AuthorizedOfficialLastName: | BECKER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7274437700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WEST CENTRAL GASTROENTEROLOGY | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | ME0054832 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 250263100 | 05 | FL | MEDICAID |