Provider Demographics
NPI:1295761666
Name:BLAIR GASTROENTEROLOGY ASSOCIATES
Entity type:Organization
Organization Name:BLAIR GASTROENTEROLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SHAREHOLDER
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCKIBBIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-946-5469
Mailing Address - Street 1:810 VALLEY VIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-6342
Mailing Address - Country:US
Mailing Address - Phone:814-946-5469
Mailing Address - Fax:814-946-4970
Practice Address - Street 1:810 VALLEY VIEW BLVD
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-6342
Practice Address - Country:US
Practice Address - Phone:814-946-5469
Practice Address - Fax:814-946-4970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD439868291U00000X
207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007453710006Medicaid
PA157086Medicare PIN