Provider Demographics
NPI:1215359484
Name:ADVANCED GASTROENTEROLOGY & COLON CANCER SCREENING CENTER LLC
Entity Type:Organization
Organization Name:ADVANCED GASTROENTEROLOGY & COLON CANCER SCREENING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TARIK
Authorized Official - Middle Name:
Authorized Official - Last Name:FIROZI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-207-0900
Mailing Address - Street 1:14803 STRAUB HILL LN
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-7965
Mailing Address - Country:US
Mailing Address - Phone:618-207-0900
Mailing Address - Fax:
Practice Address - Street 1:763 S NEW BALLAS RD # 265
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8704
Practice Address - Country:US
Practice Address - Phone:618-207-0900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008030945207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty