Provider Demographics
NPI:1659506004
Name:GASTROENTEROLOGY ASSOCIATES WEST PC
Entity Type:Organization
Organization Name:GASTROENTEROLOGY ASSOCIATES WEST PC
Other - Org Name:JACK L. MAULDIN, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:L
Authorized Official - Last Name:MAULDIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-786-5527
Mailing Address - Street 1:833 PRINCETON AVE SW
Mailing Address - Street 2:SUITE 200D
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35211-1323
Mailing Address - Country:US
Mailing Address - Phone:205-786-5527
Mailing Address - Fax:205-786-5529
Practice Address - Street 1:833 PRINCETON AVE SW
Practice Address - Street 2:SUITE 200D
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35211-1323
Practice Address - Country:US
Practice Address - Phone:205-786-5527
Practice Address - Fax:205-786-5529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-28
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6455207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000004027Medicaid
AL000004027Medicaid
ALC72967Medicare UPIN