Provider Demographics
NPI:1750562492
Name:ETOWAH GASTROENTEROLOGY ASSOCIATES PC
Entity type:Organization
Organization Name:ETOWAH GASTROENTEROLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:VIPUL
Authorized Official - Middle Name:T
Authorized Official - Last Name:AMIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-467-4477
Mailing Address - Street 1:1026 GOODYEAR AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35903-1194
Mailing Address - Country:US
Mailing Address - Phone:256-467-4477
Mailing Address - Fax:256-467-4830
Practice Address - Street 1:1026 GOODYEAR AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35903-1194
Practice Address - Country:US
Practice Address - Phone:256-467-4477
Practice Address - Fax:256-467-4830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-23
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD23716174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009969840Medicaid
AL51523153OtherBCBS
ALG48153Medicare UPIN
AL51523153OtherBCBS