Provider Demographics
NPI:1790956472
Name:SANTA ROSA GASTROENTEROLOGY
Entity type:Organization
Organization Name:SANTA ROSA GASTROENTEROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KERI
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUSYNYK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-748-4420
Mailing Address - Street 1:5992 BERRYHILL RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-1013
Mailing Address - Country:US
Mailing Address - Phone:850-626-9626
Mailing Address - Fax:850-626-9606
Practice Address - Street 1:5992 BERRYHILL RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-1013
Practice Address - Country:US
Practice Address - Phone:850-626-9626
Practice Address - Fax:850-626-9606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH84831Medicare UPIN