Healthcare Provider Details

I. General information

NPI: 1750609129
Provider Name (Legal Business Name): PEDIATRIC GASTROENTEROLOGY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2010
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 SPRINT DR STE B
CARLISLE PA
17015-7789
US

IV. Provider business mailing address

11 SPRINT DR STE B
CARLISLE PA
17015-7789
US

V. Phone/Fax

Practice location:
  • Phone: 717-422-5546
  • Fax: 171-422-5589
Mailing address:
  • Phone: 717-422-5546
  • Fax: 171-422-5589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberMD-423954
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1010342670001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: DR. MUHAMMAD AZIM QURESHI
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 717-220-4221