Provider Demographics
NPI:1861507030
Name:VALLEY GASTROENTEROLOGY PS
Entity Type:Organization
Organization Name:VALLEY GASTROENTEROLOGY PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:M
Authorized Official - Last Name:CRAIG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-922-2055
Mailing Address - Street 1:12401 E SINTO AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-1081
Mailing Address - Country:US
Mailing Address - Phone:509-922-2055
Mailing Address - Fax:
Practice Address - Street 1:12401 E SINTO AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1081
Practice Address - Country:US
Practice Address - Phone:509-922-2055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601915471174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7104243Medicaid
WA7104243Medicaid