Provider Demographics
NPI:1720035439
Name:GASTROENTEROLOGY ASSOCIATES OF SOUTHEAST MO, PC
Entity Type:Organization
Organization Name:GASTROENTEROLOGY ASSOCIATES OF SOUTHEAST MO, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CROCETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-334-8870
Mailing Address - Street 1:1429 N MOUNT AUBURN RD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2171
Mailing Address - Country:US
Mailing Address - Phone:573-334-8870
Mailing Address - Fax:573-334-7340
Practice Address - Street 1:1429 N MOUNT AUBURN RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2171
Practice Address - Country:US
Practice Address - Phone:573-334-8870
Practice Address - Fax:573-334-7340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO502633506Medicaid
MO502633506Medicaid