Provider Demographics
NPI:1255717641
Name:ST PETERSBURG GASTROENTEROLOGY ASSOCIATES LLC
Entity type:Organization
Organization Name:ST PETERSBURG GASTROENTEROLOGY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:MR
Authorized Official - First Name:ELIE
Authorized Official - Middle Name:
Authorized Official - Last Name:AYYUB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-322-1054
Mailing Address - Street 1:2763 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-8723
Mailing Address - Country:US
Mailing Address - Phone:727-820-1039
Mailing Address - Fax:727-822-8081
Practice Address - Street 1:1839 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-8900
Practice Address - Country:US
Practice Address - Phone:727-820-1040
Practice Address - Fax:727-822-8081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-07
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10833207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty