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General NPI Number Information
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NPI Number | 1790233401
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Entity Type | Organization
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Legal Business Name | INNOVATIVE GASTROENTEROLOGY, INC
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Dates
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Enumeration Date | 09/12/2016
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Last Update Date | 09/12/2016
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Provider Practice Location Address
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Address Line | 6210 SCOTT ST SUITE 216
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City | PUNTA GORDA
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State | FL
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Zip | 33950-3901
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Country | US
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Telephone | 941-378-3871
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Fax |
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Provider Business Mailing Address
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Address Line | 6210 SCOTT ST SUITE 216
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City | PUNTA GORDA
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State | FL
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Zip | 33950-3901
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Country | US
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Telephone | 941-378-3871
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Fax |
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Authorized Official
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Title or Position | MEDICAL BILLING MANAGER
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Name | KOSONDRA GRANT
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Credential |
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Telephone | 770-485-1447
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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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