Provider Demographics
NPI:1720129893
Name:PACIFIC GASTROENTEROLOGY ENDOSCOPY CENTER
Entity Type:Organization
Organization Name:PACIFIC GASTROENTEROLOGY ENDOSCOPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OM
Authorized Official - Middle Name:P
Authorized Official - Last Name:CHAURASIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-365-8836
Mailing Address - Street 1:26421 CROWN VALLEY PKWY
Mailing Address - Street 2:SUITE 140B
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-8564
Mailing Address - Country:US
Mailing Address - Phone:949-365-8836
Mailing Address - Fax:
Practice Address - Street 1:26421 CROWN VALLEY PKWY
Practice Address - Street 2:SUITE 140B
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-8564
Practice Address - Country:US
Practice Address - Phone:949-365-8836
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA060000855261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA060000855OtherSTATE FACILITY LICENSE
CAAS1598OtherBLUE CROSS FACILITY ID
CAZZZH3075ZOtherBLUE SHIELD FACILITY ID
CA060000855OtherSTATE FACILITY LICENSE