Healthcare Provider Details

I. General information

NPI: 1306843842
Provider Name (Legal Business Name): TRI-STATE GASTROENTEROLOGY ASSOCIATES, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 10/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 CENTRE VIEW BLVD
CRESTVIEW HILLS KY
41017-3409
US

IV. Provider business mailing address

425 CENTRE VIEW BLVD
CRESTVIEW HILLS KY
41017-3409
US

V. Phone/Fax

Practice location:
  • Phone: 859-341-3575
  • Fax: 859-341-5701
Mailing address:
  • Phone: 859-341-3575
  • Fax: 859-341-5701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. DANIEL G FAGEL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 859-341-3575