Provider Demographics
NPI:1588622856
Name:MERIDIAN GASTROENTEROLOGY, PLLC
Entity Type:Organization
Organization Name:MERIDIAN GASTROENTEROLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:DUNGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-703-9165
Mailing Address - Street 1:PO BOX 1769
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-1769
Mailing Address - Country:US
Mailing Address - Phone:601-703-9506
Mailing Address - Fax:601-703-3264
Practice Address - Street 1:1800 12TH ST
Practice Address - Street 2:SUITE 1D
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4158
Practice Address - Country:US
Practice Address - Phone:601-703-9165
Practice Address - Fax:601-703-9483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DA7569OtherRAILROAD MEDICARE
=========OtherTRICARE
C03005Medicare ID - Type Unspecified