Basic Information
Provider Information | |||||||||
NPI: | 1629142211 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BAY AREA GASTROENTEROLOGY, PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1015 MEDICAL CENTER BLVD | ||||||||
Address2: | SUITE 1700 | ||||||||
City: | WEBSTER | ||||||||
State: | TX | ||||||||
PostalCode: | 775984011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2814040360 | ||||||||
FaxNumber: | 2814804046 | ||||||||
Practice Location | |||||||||
Address1: | 1015 MEDICAL CENTER BLVD | ||||||||
Address2: | SUITE 1700 | ||||||||
City: | WEBSTER | ||||||||
State: | TX | ||||||||
PostalCode: | 775984011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2814040360 | ||||||||
FaxNumber: | 2814804046 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/17/2006 | ||||||||
LastUpdateDate: | 03/17/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MANI | ||||||||
AuthorizedOfficialFirstName: | RAVI | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2814040360 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | H0110 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 00784N | 01 | TX | BCBS | OTHER | 10005940 | 01 | TX | AMERIGROUP MCARE MCAID | OTHER |