Provider Demographics
NPI:1073106639
Name:PGR GASTRO LLC
Entity Type:Organization
Organization Name:PGR GASTRO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING EX
Authorized Official - Prefix:
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-313-0438
Mailing Address - Street 1:457 ALTER AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-2310
Mailing Address - Country:US
Mailing Address - Phone:718-979-9790
Mailing Address - Fax:718-979-9798
Practice Address - Street 1:774 DUMONT PL
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-3122
Practice Address - Country:US
Practice Address - Phone:718-979-9790
Practice Address - Fax:718-979-9798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-15
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopyGroup - Multi-Specialty