Basic Information
| Provider Information | |||||||||
| NPI: | 1609953942 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ENDOSCOPY CENTER OF OCALA INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1901 SE 18TH AVE | ||||||||
| Address2: | BUILDING #400 | ||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344718215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527328905 | ||||||||
| FaxNumber: | 3527322307 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 SE 18TH AVE | ||||||||
| Address2: | BUILDING #400 | ||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344718215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527328905 | ||||||||
| FaxNumber: | 3527322440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 12/21/2010 | ||||||||
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| AuthorizedOfficialLastName: | EMERSON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3526713882 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 3751791-00 | 05 | FL | MEDICAID |