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General NPI Number Information
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NPI Number | 1235246240
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Entity Type | Organization
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Legal Business Name | PREMIER GASTROENTEROLOGY PA
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Dates
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Enumeration Date | 08/24/2006
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Last Update Date | 06/10/2024
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Provider Practice Location Address
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Address Line | 12102 CORTEZ BLVD
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City | BROOKSVILLE
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State | FL
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Zip | 34613-5514
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Country | US
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Telephone | 352-597-4000
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Fax | 352-597-0550
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Provider Business Mailing Address
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Address Line | 12102 CORTEZ BLVD
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City | BROOKSVILLE
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State | FL
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Zip | 34613-5514
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Country | US
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Telephone | 352-597-4000
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Fax | 352-597-0550
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Authorized Official
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Title or Position | OWNER/CEO
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Name | DR. MUHAMMED-RODWAN ALI HIBA
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Credential | MD
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Telephone | 352-597-4000
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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 | ME69833
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License Number State | FL
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