Healthcare Provider Details

I. General information

NPI: 1154758050
Provider Name (Legal Business Name): SHOALS GASTROENTEROLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2013
Last Update Date: 10/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 CLOYD BLVD SUITE 8-B
FLORENCE AL
35630-7512
US

IV. Provider business mailing address

PO BOX 298
FLORENCE AL
35631-0298
US

V. Phone/Fax

Practice location:
  • Phone: 256-381-6304
  • Fax: 256-381-6307
Mailing address:
  • Phone: 256-767-7494
  • Fax: 256-765-0377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. ABHINANDANA ANANTHARAJU
Title or Position: SOLE MEMBER/PHYSICIAN
Credential:
Phone: 256-381-6304