Basic Information
| Provider Information | |||||||||
| NPI: | 1750346748 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GASTROENTEROLOGY ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 N CENTER ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286015036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283283300 | ||||||||
| FaxNumber: | 8283283288 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 N CENTER ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286015036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283283300 | ||||||||
| FaxNumber: | 8283283288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 07/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | RAND | ||||||||
| AuthorizedOfficialFirstName: | REVONDA | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8283283300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 890211T | 05 | NC | MEDICAID |