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General NPI Number Information
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NPI Number | 1285707885
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Entity Type | Organization
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Legal Business Name | COMMONWEALTH GASTROENTEROLOGY ASSOCIATES, PLLC
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Dates
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Enumeration Date | 11/15/2006
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Last Update Date | 05/05/2008
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Provider Practice Location Address
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Address Line | 177 BURT RD BURT ROAD MEDICAL CLINIC
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City | LEXINGTON
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State | KY
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Zip | 40503-2410
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Country | US
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Telephone | 859-967-2055
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Fax | 859-278-8488
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Provider Business Mailing Address
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Address Line | 177 BURT RD BURT ROAD MEDICAL CLINIC
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City | LEXINGTON
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State | KY
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Zip | 40503-2410
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Country | US
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Telephone | 859-967-2055
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Fax | 859-278-8488
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. BRYAN KELLER STADIG
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Credential | MBA, CMPE
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Telephone | 859-967-2055
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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 |
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License Number State |
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