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General NPI Number Information
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NPI Number | 1306843842
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Entity Type | Organization
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Legal Business Name | TRI-STATE GASTROENTEROLOGY ASSOCIATES, PSC
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Dates
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Enumeration Date | 06/30/2005
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Last Update Date | 10/07/2014
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Provider Practice Location Address
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Address Line | 425 CENTRE VIEW BLVD
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City | CRESTVIEW HILLS
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State | KY
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Zip | 41017-3409
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Country | US
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Telephone | 859-341-3575
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Fax | 859-341-5701
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Provider Business Mailing Address
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Address Line | 425 CENTRE VIEW BLVD
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City | CRESTVIEW HILLS
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State | KY
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Zip | 41017-3409
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Country | US
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Telephone | 859-341-3575
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Fax | 859-341-5701
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DANIEL G FAGEL
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Credential | M.D.
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Telephone | 859-341-3575
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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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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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