Provider Demographics
NPI:1003992090
Name:ADVANCED GASTROENTEROLOGY, PLLC
Entity type:Organization
Organization Name:ADVANCED GASTROENTEROLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:SIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-946-4313
Mailing Address - Street 1:3250 SE 164TH AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9313
Mailing Address - Country:US
Mailing Address - Phone:360-946-4313
Mailing Address - Fax:360-314-2067
Practice Address - Street 1:3250 SE 164TH AVE STE 205
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-9313
Practice Address - Country:US
Practice Address - Phone:360-946-4313
Practice Address - Fax:360-576-1133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042129207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8856933Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER