Provider Demographics
NPI:1083851042
Name:ADVANCED GASTROENTEROLOGY, LLC
Entity Type:Organization
Organization Name:ADVANCED GASTROENTEROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:812-885-8770
Mailing Address - Street 1:PO BOX 3276
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47731-3276
Mailing Address - Country:US
Mailing Address - Phone:812-473-0181
Mailing Address - Fax:812-473-5822
Practice Address - Street 1:520 S 7TH ST STE SB406
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1038
Practice Address - Country:US
Practice Address - Phone:812-885-8770
Practice Address - Fax:812-885-8771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-13
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300012584Medicaid
ININ3764OtherMEDICARE
INE49700Medicare UPIN