Healthcare Provider Details

I. General information

NPI: 1508942665
Provider Name (Legal Business Name): THE ENDOSCOPY CENTER AT GATEWAY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 09/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 NORTHAMPTON STREET
EDWARDSVILLE PA
18704
US

IV. Provider business mailing address

490 NORTHAMPTON STREET
EDWARDSVILLE PA
18704
US

V. Phone/Fax

Practice location:
  • Phone: 570-288-8100
  • Fax: 570-714-2733
Mailing address:
  • Phone: 570-288-8100
  • Fax: 570-714-2733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARTIN BARRY FRIED
Title or Position: OWNER
Credential: MD
Phone: 570-288-8100