Provider Demographics
NPI:1649539255
Name:ARIZONA GASTROENTEROLOGY CLINIC LLC
Entity type:Organization
Organization Name:ARIZONA GASTROENTEROLOGY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DALJIT
Authorized Official - Middle Name:SINGH
Authorized Official - Last Name:BAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-773-1161
Mailing Address - Street 1:14155 N 83RD AVE STE 122
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-5640
Mailing Address - Country:US
Mailing Address - Phone:623-773-1161
Mailing Address - Fax:623-773-1181
Practice Address - Street 1:14155 N 83RD AVE STE 122
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5640
Practice Address - Country:US
Practice Address - Phone:623-773-1161
Practice Address - Fax:623-773-1181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27357207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ102207Medicare UPIN