Provider Demographics
NPI:1104835461
Name:PREMIER GASTROENTEROLOGY, P. C.
Entity Type:Organization
Organization Name:PREMIER GASTROENTEROLOGY, P. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TARIQ
Authorized Official - Middle Name:A
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-349-6113
Mailing Address - Street 1:PO BOX 40895
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38174-0895
Mailing Address - Country:US
Mailing Address - Phone:662-349-6113
Mailing Address - Fax:662-349-6188
Practice Address - Street 1:7900 AIRWAYS BLVD
Practice Address - Street 2:BLDG A STE 3A
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-4113
Practice Address - Country:US
Practice Address - Phone:662-349-6113
Practice Address - Fax:662-349-6188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015473Medicaid
TN3150548OtherBLUE CROSS
MS631263936EOtherBLUE CROSS
MS100000139Medicare PIN
TN3815396Medicare PIN
TN3150548OtherBLUE CROSS