Provider Demographics
NPI:1760629497
Name:CHILDREN'S GASTROENTEROLOGY OF SW FLORIDA
Entity Type:Organization
Organization Name:CHILDREN'S GASTROENTEROLOGY OF SW FLORIDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSIORU ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-689-5100
Mailing Address - Street 1:9800 S HEALTHPARK DRIVE
Mailing Address - Street 2:SUITE 145
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908
Mailing Address - Country:US
Mailing Address - Phone:239-689-5100
Mailing Address - Fax:
Practice Address - Street 1:9800 S HEALTHPARK DRIVE
Practice Address - Street 2:SUITE 145
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908
Practice Address - Country:US
Practice Address - Phone:239-689-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-16
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME692562080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253328600Medicaid
FLF33939Medicare UPIN