Provider Demographics
NPI:1518975879
Name:GASTROENTEROLOGY ASSOCIATES OF THE SOUTH BAY A PROFESS MEDICAL CORP
Entity Type:Organization
Organization Name:GASTROENTEROLOGY ASSOCIATES OF THE SOUTH BAY A PROFESS MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:H
Authorized Official - Last Name:TAKEMURA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-214-7236
Mailing Address - Street 1:20911 EARL STREET
Mailing Address - Street 2:SUITE 280
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503
Mailing Address - Country:US
Mailing Address - Phone:310-214-7236
Mailing Address - Fax:310-542-0334
Practice Address - Street 1:20911 EARL STREET
Practice Address - Street 2:SUITE 280
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503
Practice Address - Country:US
Practice Address - Phone:310-214-7236
Practice Address - Fax:310-542-0334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29961207RG0100X
CAG58448207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA100011914OtherRAILROAD
CA100008536OtherRAILROAD
CA100011914OtherRAILROAD
CAE85732Medicare UPIN
CAA44239Medicare UPIN
A44239Medicare UPIN
CAW11307AMedicare PIN