Basic Information
Provider Information
NPI: 1629142211
EntityType: 2
ReplacementNPI:  
OrganizationName: BAY AREA GASTROENTEROLOGY, PA
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
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Credential:  
OtherOrganizationName:  
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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
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RG0100XH0110TXY193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology

ID Information
IDTypeStateIssuerDescription
00784N01TXBCBSOTHER
1000594001TXAMERIGROUP MCARE MCAIDOTHER


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