Provider Demographics
NPI:1255464749
Name:GREATER NORTHEAST GASTROENTEROLOGY ASSOCIATES PC
Entity type:Organization
Organization Name:GREATER NORTHEAST GASTROENTEROLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:MERMELSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-634-5595
Mailing Address - Street 1:7439 FRANKFORD AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19136-3600
Mailing Address - Country:US
Mailing Address - Phone:215-333-1377
Mailing Address - Fax:215-333-1399
Practice Address - Street 1:7439 FRANKFORD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19136
Practice Address - Country:US
Practice Address - Phone:215-333-1377
Practice Address - Fax:215-333-1399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD033183E207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011228030002Medicaid
PAME115096Medicare ID - Type Unspecified
PAB36990Medicare UPIN