Basic Information
| Provider Information | |||||||||
| NPI: | 1750693537 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GASTROINTESTINAL ASSOCIATES WEST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11440 PARKSIDE DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379342658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655885121 | ||||||||
| FaxNumber: | 8655882126 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 N WEISGARBER RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379092706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655885121 | ||||||||
| FaxNumber: | 8655882126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2010 | ||||||||
| LastUpdateDate: | 07/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | OVERHOLT | ||||||||
| AuthorizedOfficialFirstName: | BERGEIN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8655885121 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GASTROINTESTINAL ASSOCIATES PC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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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 |
No ID Information.