Provider Demographics
NPI:1821022161
Name:GASTROENTEROLOGY ASSOCIATES PC
Entity Type:Organization
Organization Name:GASTROENTEROLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ERLING
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:563-383-2686
Mailing Address - Street 1:2222 53RD AVENUE
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52753
Mailing Address - Country:US
Mailing Address - Phone:563-383-2686
Mailing Address - Fax:563-884-8144
Practice Address - Street 1:2222 53RD AVENUE
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52753
Practice Address - Country:US
Practice Address - Phone:563-383-2686
Practice Address - Fax:563-884-8144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0455097Medicaid
IA71951OtherMEDICARE GROUP #
IA0455097Medicaid