Provider Demographics
NPI:1780631127
Name:GASTROENTEROLOGY AND LIVER DISEASE MEDICAL CENTER INC
Entity Type:Organization
Organization Name:GASTROENTEROLOGY AND LIVER DISEASE MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:AUDRA
Authorized Official - Middle Name:E
Authorized Official - Last Name:ORBAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-760-9981
Mailing Address - Street 1:7215 N FRESNO ST
Mailing Address - Street 2:#101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2969
Mailing Address - Country:US
Mailing Address - Phone:559-449-0309
Mailing Address - Fax:559-449-0609
Practice Address - Street 1:7215 N FRESNO ST
Practice Address - Street 2:#101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2969
Practice Address - Country:US
Practice Address - Phone:559-449-0309
Practice Address - Fax:559-449-0609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAS1593001261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZH1024ZOtherBLUE SHIELD
CASUR01593FMedicaid
CAZZZH1024ZOtherBLUE SHIELD