Provider Demographics
NPI:1366442642
Name:GASTROENTEROLOGY CLINIC, A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:GASTROENTEROLOGY CLINIC, A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:W
Authorized Official - Last Name:WALDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-325-2634
Mailing Address - Street 1:611 GRAMMONT ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7516
Mailing Address - Country:US
Mailing Address - Phone:318-325-2634
Mailing Address - Fax:318-812-1205
Practice Address - Street 1:611 GRAMMONT ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-7516
Practice Address - Country:US
Practice Address - Phone:318-325-2634
Practice Address - Fax:318-812-1205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
23704OtherBLUE CROSS OF LOUISIANA
LA1798240Medicaid
LA5C277Medicare ID - Type Unspecified