Provider Demographics
NPI:1376572644
Name:ADVANCED GASTROENTEROLOGY AFFILIATES PA
Entity Type:Organization
Organization Name:ADVANCED GASTROENTEROLOGY AFFILIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:NAEEM
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-352-1303
Mailing Address - Street 1:7448 DOCS GROVE CIR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-8010
Mailing Address - Country:US
Mailing Address - Phone:407-352-1303
Mailing Address - Fax:407-352-3833
Practice Address - Street 1:7448 DOCS GROVE CIR
Practice Address - Street 2:SUITE 200
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-8010
Practice Address - Country:US
Practice Address - Phone:407-352-1303
Practice Address - Fax:407-352-3833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72852207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDB533AMedicare PIN