=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689163982
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER GASTROENTEROLOGY ASSOCIATES-ANES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2018
-----------------------------------------------------
Last Update Date | 05/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10001 LILE DR STE 200
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72205-6217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-747-2828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1701 CENTERVIEW DR STE 312
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72211-4313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-747-2828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TERENCE L ANGTUACO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 501-747-2828
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------