Provider Demographics
NPI:1649233719
Name:GI ASC LLC
Entity type:Organization
Organization Name:GI ASC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELYSE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRULLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-664-9700
Mailing Address - Street 1:10 PRESIDENTIAL BLVD
Mailing Address - Street 2:SUITE 124
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1107
Mailing Address - Country:US
Mailing Address - Phone:610-664-9700
Mailing Address - Fax:610-664-6391
Practice Address - Street 1:3998 RED LION RD
Practice Address - Street 2:SUITE 240 - CANCER CENTER
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1436
Practice Address - Country:US
Practice Address - Phone:215-632-3500
Practice Address - Fax:215-632-6533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA06181500261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013216400001Medicaid
PA093168Medicare ID - Type Unspecified