Provider Demographics
NPI:1912275538
Name:PATTERSON GASTROENTEROLOGY PLLC
Entity Type:Organization
Organization Name:PATTERSON GASTROENTEROLOGY PLLC
Other - Org Name:PATTERSON PEDIATRIC GASTROENTEROLOGY PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MEDICAL DOCTOR
Authorized Official - Phone:602-283-3165
Mailing Address - Street 1:PO BOX 90482
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85066-0482
Mailing Address - Country:US
Mailing Address - Phone:602-283-3165
Mailing Address - Fax:602-283-3612
Practice Address - Street 1:515 W BUCKEYE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85003-2647
Practice Address - Country:US
Practice Address - Phone:602-283-3165
Practice Address - Fax:602-283-3612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20901261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ127820Medicaid
AZ127820Medicaid