Healthcare Provider Details

I. General information

NPI: 1396063673
Provider Name (Legal Business Name): GATEWAY ENDOSCOPY CENTER, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2010
Last Update Date: 06/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12855 N 40 DR STE 150
SAINT LOUIS MO
63141-8657
US

IV. Provider business mailing address

12855 N 40 DR STE 150
SAINT LOUIS MO
63141-8657
US

V. Phone/Fax

Practice location:
  • Phone: 314-336-1130
  • Fax: 314-336-1136
Mailing address:
  • Phone: 314-336-1130
  • Fax: 314-336-1136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number234-0
License Number StateMO

VIII. Authorized Official

Name: KATHERINE L REED
Title or Position: MEDICARE AUTHORIZED OFFICIAL
Credential:
Phone: 972-763-3859