Provider Demographics
NPI:1366487720
Name:MITRE GASTROENTEROLOGY ASSOCIATES
Entity Type:Organization
Organization Name:MITRE GASTROENTEROLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:MITRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:412-321-1648
Mailing Address - Street 1:925 BRIGHTON RD
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15233-1707
Mailing Address - Country:US
Mailing Address - Phone:412-321-1648
Mailing Address - Fax:412-321-4216
Practice Address - Street 1:925 BRIGHTON RD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15233-1707
Practice Address - Country:US
Practice Address - Phone:412-321-1648
Practice Address - Fax:412-321-4216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD032806L207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1009520810001Medicaid
NJ1568734OtherBLUE CROSS BLUE SHIELD
NJ1568734OtherBLUE CROSS BLUE SHIELD