Healthcare Provider Details

I. General information

NPI: 1083747380
Provider Name (Legal Business Name): GASTROENTEROLOGY SPECIALTIES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 R ST
LINCOLN NE
68503-3799
US

IV. Provider business mailing address

4545 R ST
LINCOLN NE
68503-3799
US

V. Phone/Fax

Practice location:
  • Phone: 402-465-4545
  • Fax: 402-465-3621
Mailing address:
  • Phone: 402-465-4545
  • Fax: 402-465-3621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number001-005685907
License Number StateNE

VIII. Authorized Official

Name: DR. MARK G GRIFFIN
Title or Position: BOARD PRESIDENT
Credential: MD
Phone: 402-465-4545