Healthcare Provider Details

I. General information

NPI: 1073106639
Provider Name (Legal Business Name): PGR GASTRO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2021
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

774 DUMONT PL
VALLEY STREAM NY
11581-3122
US

IV. Provider business mailing address

457 ALTER AVE
STATEN ISLAND NY
10305-2310
US

V. Phone/Fax

Practice location:
  • Phone: 718-979-9790
  • Fax: 718-979-9798
Mailing address:
  • Phone: 718-979-9790
  • Fax: 718-979-9798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROSS BROWN
Title or Position: CREDENTIALING EX
Credential:
Phone: 718-313-0438