Provider Demographics
NPI:1245771252
Name:PEDIATRIC GASTROENTEROLOGY INC
Entity Type:Organization
Organization Name:PEDIATRIC GASTROENTEROLOGY INC
Other - Org Name:PEDIATRIC GASTROENTEROLOGY OF ALASKA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:AJAY
Authorized Official - Middle Name:D
Authorized Official - Last Name:GOHIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-770-2880
Mailing Address - Street 1:PO BOX 241769
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99524-1769
Mailing Address - Country:US
Mailing Address - Phone:907-770-2380
Mailing Address - Fax:907-770-2390
Practice Address - Street 1:4500 BUSINESS PARK BLVD
Practice Address - Street 2:SUITE C-10
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503
Practice Address - Country:US
Practice Address - Phone:907-770-2880
Practice Address - Fax:907-770-2882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-10
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1019132080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015979100Medicaid