Basic Information
| Provider Information | |||||||||
| NPI: | 1972697936 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GASTROENTEROLOGY ASSOCIATES OF PENSACOLA PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4828 N DAVIS HWY | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325032341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504778109 | ||||||||
| FaxNumber: | 8504782412 | ||||||||
| Practice Location | |||||||||
| Address1: | 4810 N DAVIS HWY | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325032341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504748988 | ||||||||
| FaxNumber: | 8504765312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 03/01/2018 | ||||||||
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| AuthorizedOfficialLastName: | DUNN | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR/CFO | ||||||||
| AuthorizedOfficialTelephone: | 8504748988 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | K0360 | 01 | FL | MEDICARE FLORIDA | OTHER | 529921190 | 01 | AL | MEDICAID OF AL | OTHER |