Provider Demographics
NPI:1386185858
Name:STEWARD MEDICAL GROUP PENNSYLVANIA ENDOSCOPY LLC
Entity Type:Organization
Organization Name:STEWARD MEDICAL GROUP PENNSYLVANIA ENDOSCOPY LLC
Other - Org Name:TWIN RIVERS ENDOSCOPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-562-5359
Mailing Address - Street 1:77 WARREN ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3601
Mailing Address - Country:US
Mailing Address - Phone:617-562-5359
Mailing Address - Fax:
Practice Address - Street 1:77 WARREN ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3601
Practice Address - Country:US
Practice Address - Phone:617-562-5359
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-16
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty