Provider Demographics
NPI:1790073567
Name:BENBROOK GASTROENTEROLOGY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:BENBROOK GASTROENTEROLOGY ASSOCIATES, LLC
Other - Org Name:BENBROOK GASTROENTEROLOGY ASSOC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:724-482-6062
Mailing Address - Street 1:104 TECHNOLOGY DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BUTLER
Mailing Address - State:PA
Mailing Address - Zip Code:16001-1801
Mailing Address - Country:US
Mailing Address - Phone:724-482-6062
Mailing Address - Fax:724-482-6117
Practice Address - Street 1:104 TECHNOLOGY DR
Practice Address - Street 2:SUITE 202
Practice Address - City:BUTLER
Practice Address - State:PA
Practice Address - Zip Code:16001-1801
Practice Address - Country:US
Practice Address - Phone:724-482-6062
Practice Address - Fax:724-482-6117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007169L207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty