Provider Demographics
NPI:1639560675
Name:NORTH SHORE GASTROENTEROLOGY, INC
Entity Type:Organization
Organization Name:NORTH SHORE GASTROENTEROLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING & CONTRACTING COORD
Authorized Official - Prefix:
Authorized Official - First Name:JANENE
Authorized Official - Middle Name:
Authorized Official - Last Name:WEILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-808-1212
Mailing Address - Street 1:850 COLUMBIA RD STE 200
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-7215
Mailing Address - Country:US
Mailing Address - Phone:440-808-1212
Mailing Address - Fax:440-808-0321
Practice Address - Street 1:850 COLUMBIA RD
Practice Address - Street 2:SUITE 200
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-1493
Practice Address - Country:US
Practice Address - Phone:440-808-1212
Practice Address - Fax:440-808-0321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCOA16300-NPOtherOHIO LICENSE