Provider Demographics
NPI:1245424696
Name:SPARTA GASTROENTEROLOGY LLC
Entity Type:Organization
Organization Name:SPARTA GASTROENTEROLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DMITRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MYSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-579-3174
Mailing Address - Street 1:376 LAFAYETTE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-3560
Mailing Address - Country:US
Mailing Address - Phone:973-579-3174
Mailing Address - Fax:973-579-2961
Practice Address - Street 1:376 LAFAYETTE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871
Practice Address - Country:US
Practice Address - Phone:973-579-3174
Practice Address - Fax:973-579-2961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA065097207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8503206Medicaid
NJ8503206Medicaid
NJ116954Medicare PIN