Healthcare Provider Details

I. General information

NPI: 1083851042
Provider Name (Legal Business Name): ADVANCED GASTROENTEROLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2009
Last Update Date: 11/05/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 S 7TH ST STE SB406
VINCENNES IN
47591-1038
US

IV. Provider business mailing address

PO BOX 3276
EVANSVILLE IN
47731-3276
US

V. Phone/Fax

Practice location:
  • Phone: 812-885-8770
  • Fax: 812-885-8771
Mailing address:
  • Phone: 812-473-0181
  • Fax: 812-473-5822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. REGINALD SANDY
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 812-885-8770