=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649539255
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARIZONA GASTROENTEROLOGY CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2012
-----------------------------------------------------
Last Update Date | 05/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14155 N 83RD AVE STE 122
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85381-5640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-773-1161
-----------------------------------------------------
Fax | 623-773-1181
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14155 N 83RD AVE STE 122
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85381-5640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-773-1161
-----------------------------------------------------
Fax | 623-773-1181
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DALJIT SINGH BAL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 623-773-1161
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 27357
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------