Provider Demographics
NPI:1003099904
Name:GASTROENTEROLOGY SPECIALIST PC
Entity Type:Organization
Organization Name:GASTROENTEROLOGY SPECIALIST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:J
Authorized Official - Last Name:ATKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-975-9100
Mailing Address - Street 1:1179 E PARIS AVE SE STE 200
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3682
Mailing Address - Country:US
Mailing Address - Phone:616-975-9100
Mailing Address - Fax:616-975-1161
Practice Address - Street 1:1179 E PARIS AVE SE STE 200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3682
Practice Address - Country:US
Practice Address - Phone:616-975-9100
Practice Address - Fax:616-975-1161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION99550Medicare PIN