Healthcare Provider Details

I. General information

NPI: 1548234289
Provider Name (Legal Business Name): GASTROENTEROLOGY CONSULTANTS MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 11/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8120 TIMBERLAKE WAY STE 101
SACRAMENTO CA
95823-5412
US

IV. Provider business mailing address

8120 TIMBERLAKE WAY STE 101
SACRAMENTO CA
95823-5412
US

V. Phone/Fax

Practice location:
  • Phone: 916-423-2124
  • Fax: 916-423-2127
Mailing address:
  • Phone: 916-423-2124
  • Fax: 916-423-2127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberFNP 5539
License Number StateCA

VIII. Authorized Official

Name: TINA MARIE JOHNSTON
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 916-423-2123