Provider Demographics
NPI:1902862071
Name:GASTROENTEROLOGY LTD
Entity Type:Organization
Organization Name:GASTROENTEROLOGY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:JANSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-481-5730
Mailing Address - Street 1:1717 WILL O'WISP DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2409
Mailing Address - Country:US
Mailing Address - Phone:757-481-4817
Mailing Address - Fax:757-481-7138
Practice Address - Street 1:1717 WILL O'WISP DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2409
Practice Address - Country:US
Practice Address - Phone:757-481-4817
Practice Address - Fax:757-481-7138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA201628793174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1902862071Medicaid
VA201628793OtherTAX ID NUMBER
VA=========OtherTAX ID NUMBER
VAC09317Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER