Basic Information
| Provider Information | |||||||||
| NPI: | 1578741401 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GASTROENTEROLOGY MEDICAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1580 CREEKSIDE DR STE 150 | ||||||||
| Address2: | |||||||||
| City: | FOLSOM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956303888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169834444 | ||||||||
| FaxNumber: | 9169838563 | ||||||||
| Practice Location | |||||||||
| Address1: | 1580 CREEKSIDE DR STE 220 | ||||||||
| Address2: | |||||||||
| City: | FOLSOM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956303888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169834444 | ||||||||
| FaxNumber: | 9169838563 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2008 | ||||||||
| LastUpdateDate: | 01/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | PECHA | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | ERICK | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9169834444 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 01/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GR0048710 | 05 | CA | MEDICAID |