Provider Demographics
NPI:1265566780
Name:GATEWAY DIGESTIVE AND LIVER SPECIALISTS, LLC
Entity type:Organization
Organization Name:GATEWAY DIGESTIVE AND LIVER SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MONTEMAYOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-454-6903
Mailing Address - Street 1:4510 DELMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-1702
Mailing Address - Country:US
Mailing Address - Phone:314-454-6903
Mailing Address - Fax:314-454-6652
Practice Address - Street 1:4510 DELMAR BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1702
Practice Address - Country:US
Practice Address - Phone:314-454-6903
Practice Address - Fax:314-454-6652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107492207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208107912Medicaid
MODC2409OtherRR MEDICARE
MODC2409OtherRR MEDICARE