Provider Demographics
NPI:1932189768
Name:CONSULTANTS IN GASTROENTEROLOGY, PC
Entity Type:Organization
Organization Name:CONSULTANTS IN GASTROENTEROLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:R
Authorized Official - Last Name:REYNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-478-4887
Mailing Address - Street 1:17501 E US HIGHWAY 40
Mailing Address - Street 2:SUITE 213A
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-5442
Mailing Address - Country:US
Mailing Address - Phone:816-478-4887
Mailing Address - Fax:816-478-7140
Practice Address - Street 1:3800 S WHITNEY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-6739
Practice Address - Country:US
Practice Address - Phone:816-478-4887
Practice Address - Fax:816-478-7140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-18
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO501536809Medicaid
MO4180000AMedicare PIN
MO4180000EMedicare PIN