Provider Demographics
NPI:1801988639
Name:CARIBE GASTROENTEROLOGY LLC
Entity type:Organization
Organization Name:CARIBE GASTROENTEROLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:DEBOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-432-2580
Mailing Address - Street 1:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-0449
Mailing Address - Country:US
Mailing Address - Phone:314-432-2580
Mailing Address - Fax:314-569-3162
Practice Address - Street 1:6 JUNGERMANN CIR
Practice Address - Street 2:SUITE 207
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1621
Practice Address - Country:US
Practice Address - Phone:636-498-1700
Practice Address - Fax:636-498-1702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507577807Medicaid
MO507577807Medicaid