=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497853303
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GASTROENTEROLOGY ASSOCIATES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2006
-----------------------------------------------------
Last Update Date | 10/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19500 SANDRIDGE WAY STE 470
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20176-3694
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-771-9001
-----------------------------------------------------
Fax | 703-771-9076
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19500 SANDRIDGE WAY STE 470
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20176-3694
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-771-9001
-----------------------------------------------------
Fax | 703-771-9076
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | STEPHEN J ANTONIK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 703-771-9001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------