Basic Information
| Provider Information | |||||||||
| NPI: | 1912900143 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | E STREET ENDOSCOPY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WEST COAST ENDOSCOPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 616 E ST | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337563342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274470888 | ||||||||
| FaxNumber: | 7274470993 | ||||||||
| Practice Location | |||||||||
| Address1: | 616 E ST | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337563342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274470888 | ||||||||
| FaxNumber: | 7274470993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 04/25/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JIRAN | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ADMINITRATIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7274470888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 1145 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 002689600 | 05 | FL | MEDICAID | 1972392 | 01 | FL | FIRST HEALTH | OTHER | 285376 | 01 | FL | AVMED | OTHER | 2894273 | 01 | FL | AETNA HMO | OTHER | 6A5 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 9131340001 | 01 | FL | CIGNA | OTHER | 490005538 | 01 | FL | RAILROAD MEDICARE | OTHER | 106705-01 | 01 | FL | CITRUS HEALTHCARE | OTHER | 7337369 | 01 | FL | AETNA | OTHER | 187028 | 01 | FL | AMERIGROUP | OTHER | 209367 | 01 | FL | WELLCARE | OTHER |