Provider Demographics
NPI:1124031141
Name:MOBILE GASTROENTEROLOGY, PC
Entity Type:Organization
Organization Name:MOBILE GASTROENTEROLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-639-2101
Mailing Address - Street 1:PO BOX 850489
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36685-0489
Mailing Address - Country:US
Mailing Address - Phone:251-639-2101
Mailing Address - Fax:251-639-9122
Practice Address - Street 1:6701 AIRPORT BLVD
Practice Address - Street 2:SUITE A-208
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-6705
Practice Address - Country:US
Practice Address - Phone:251-639-2101
Practice Address - Fax:251-639-9122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
I960OtherMEDICARE GROUP PROVIDER