Provider Demographics
NPI:1003002270
Name:SANDUSKY GASTROENTEROLOGISTS, INC.
Entity Type:Organization
Organization Name:SANDUSKY GASTROENTEROLOGISTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCCORMACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-627-1056
Mailing Address - Street 1:1410 MILAN RD
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-4130
Mailing Address - Country:US
Mailing Address - Phone:419-627-1056
Mailing Address - Fax:419-627-6269
Practice Address - Street 1:1410 MILAN RD
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-4130
Practice Address - Country:US
Practice Address - Phone:419-627-1056
Practice Address - Fax:419-627-6269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH034991207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0361791Medicaid
OHA77497Medicare UPIN
OH0361791Medicaid