Provider Demographics
NPI:1689671448
Name:CHARLOTTESVILLE GASTROENTEROLOGY ASSOCIATES PC
Entity Type:Organization
Organization Name:CHARLOTTESVILLE GASTROENTEROLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BYRD
Authorized Official - Middle Name:STUART
Authorized Official - Last Name:LEAVELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:434-817-8484
Mailing Address - Street 1:1139 E HIGH ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22902-4856
Mailing Address - Country:US
Mailing Address - Phone:434-817-8484
Mailing Address - Fax:434-817-8490
Practice Address - Street 1:1139 E HIGH ST
Practice Address - Street 2:SUITE 203
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-4856
Practice Address - Country:US
Practice Address - Phone:434-817-8484
Practice Address - Fax:434-817-8490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2953174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC01154Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER