Provider Demographics
NPI:1417141623
Name:FAYETTEVILLE GASTROENTEROLOGY ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:FAYETTEVILLE GASTROENTEROLOGY ASSOCIATES, P.A.
Other - Org Name:FAYETTEVILLE ENDOSCOPY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CASILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-323-5203
Mailing Address - Street 1:2041 VALLEYGATE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3745
Mailing Address - Country:US
Mailing Address - Phone:910-323-5203
Mailing Address - Fax:910-323-3650
Practice Address - Street 1:2041 VALLEYGATE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3745
Practice Address - Country:US
Practice Address - Phone:910-323-5203
Practice Address - Fax:910-323-3650
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAYETTEVILLE GASTROENTEROLOGY ASSOCIATES, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-30
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCAS0071261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2380979OtherMEDICARE FACILITY NUMBER