Basic Information
| Provider Information | |||||||||
| NPI: | 1740232701 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TROY GASTROENTEROLOGY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50438 VAN DYKE AVE | ||||||||
| Address2: | #B | ||||||||
| City: | SHELBY TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483171358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867268423 | ||||||||
| FaxNumber: | 5867268557 | ||||||||
| Practice Location | |||||||||
| Address1: | 4600 INVESTMENT DR | ||||||||
| Address2: | SUITE 270 | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480986365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488449710 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 09/28/2007 | ||||||||
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| AuthorizedOfficialLastName: | BOLOGNA | ||||||||
| AuthorizedOfficialFirstName: | SANTE | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2488449710 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TROY GASTROENTEROLOGY, PC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | DF4836 | 01 | MI | MEDICARE RAILROAD | OTHER |