Provider Demographics
NPI:1346289709
Name:GASTROENTEROLOGY ASSOCIATES OF SOUTHEAST ARKANSAS, P.A.
Entity Type:Organization
Organization Name:GASTROENTEROLOGY ASSOCIATES OF SOUTHEAST ARKANSAS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:O
Authorized Official - Middle Name:T
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:870-534-3344
Mailing Address - Street 1:1609 W 40TH AVE
Mailing Address - Street 2:SUITE 312
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6329
Mailing Address - Country:US
Mailing Address - Phone:870-534-3344
Mailing Address - Fax:870-534-3517
Practice Address - Street 1:1609 W 40TH AVE
Practice Address - Street 2:SUITE 312
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6329
Practice Address - Country:US
Practice Address - Phone:870-534-3344
Practice Address - Fax:870-534-3517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC5353261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C989OtherBLUE CROSS BLUE SHIELD
ARDB2069OtherRAIL ROAD MEDICARE
AR5C989Medicare ID - Type Unspecified