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General NPI Number Information
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NPI Number | 1215359484
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Entity Type | Organization
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Legal Business Name | ADVANCED GASTROENTEROLOGY & COLON CANCER SCREENING CENTER LLC
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Dates
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Enumeration Date | 01/07/2014
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Last Update Date | 01/07/2014
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Provider Practice Location Address
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Address Line | 763 S NEW BALLAS RD # 265
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City | SAINT LOUIS
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State | MO
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Zip | 63141-8704
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Country | US
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Telephone | 618-207-0900
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Fax |
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Provider Business Mailing Address
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Address Line | 14803 STRAUB HILL LN
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City | CHESTERFIELD
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State | MO
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Zip | 63017-7965
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Country | US
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Telephone | 618-207-0900
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | TARIK FIROZI
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Credential | MD
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Telephone | 618-207-0900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 2008030945
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License Number State | MO
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