Healthcare Provider Details

I. General information

NPI: 1124173596
Provider Name (Legal Business Name): GASTROENTEROLOGY ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4665 BELPAR ST NW
CANTON OH
44718-3602
US

IV. Provider business mailing address

PO BOX 36329
CANTON OH
44735-6329
US

V. Phone/Fax

Practice location:
  • Phone: 330-493-1480
  • Fax: 330-493-6805
Mailing address:
  • Phone: 330-493-1480
  • Fax: 330-493-6805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number0048A5 131
License Number StateOH

VIII. Authorized Official

Name: SANJIV K KHULLER
Title or Position: DOCTOR
Credential: MD
Phone: 330-493-1480