Healthcare Provider Details

I. General information

NPI: 1194208892
Provider Name (Legal Business Name): EL PASO CENTER FOR PEDIATRIC GASTROENTEROLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 N MESA ST STE C
EL PASO TX
79902-3575
US

IV. Provider business mailing address

2311 N MESA ST STE C
EL PASO TX
79902-3575
US

V. Phone/Fax

Practice location:
  • Phone: 915-269-0064
  • Fax:
Mailing address:
  • Phone: 915-269-0064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARIDINE CO
Title or Position: PRESIDENT
Credential: MD
Phone: 915-269-0064