Healthcare Provider Details

I. General information

NPI: 1992998975
Provider Name (Legal Business Name): EAST COAST GASTROENTEROLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 12/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 MERCANTILE LN SUITE 217
LARGO MD
20774-5376
US

IV. Provider business mailing address

PO BOX 62249
BALTIMORE MD
21264-2249
US

V. Phone/Fax

Practice location:
  • Phone: 301-583-7770
  • Fax: 301-583-9414
Mailing address:
  • Phone: 301-583-7770
  • Fax: 301-583-9414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL ROBERT NICHOLS
Title or Position: CREDENTIALING REPRESENTATIVE
Credential:
Phone: 410-258-6333