Provider Demographics
NPI:1518745017
Name:PLEXUS GASTRO PLLC
Entity Type:Organization
Organization Name:PLEXUS GASTRO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:G
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-489-9436
Mailing Address - Street 1:6501 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-4780
Mailing Address - Country:US
Mailing Address - Phone:313-315-1422
Mailing Address - Fax:313-435-0535
Practice Address - Street 1:6501 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-4780
Practice Address - Country:US
Practice Address - Phone:313-651-7053
Practice Address - Fax:313-435-0535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-18
Last Update Date:2024-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty