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NPI Code Detail

MEDICARE: FAYETTEVILLE GASTROENTEROLOGY ASSOCIATES, P.A.

MEDICARE: FAYETTEVILLE GASTROENTEROLOGY ASSOCIATES, P.A.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QE0800XEndoscopy Clinic/CenterAS0071NC

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12380979OTHERNCMEDICARE FACILITY NUMBER

General Provider Information

NPI Number : 1417141623
Entity Type Code : Organization
Provider Name (Legal Business Name) : FAYETTEVILLE GASTROENTEROLOGY ASSOCIATES, P.A.
Provider Business Mailing Address
First Line : 2041 VALLEYGATE DR
Second Line :
City : FAYETTEVILLE
State : NC
Zip : 28304-3745
Country : US
Telephone Number : 910-323-5203
Fax Number : 910-323-3650
Provider Business Practice Location Address
First Line : 2041 VALLEYGATE DR
Second Line :
City : FAYETTEVILLE
State : NC
Zip : 28304-3745
Country : US
Telephone Number : 910-323-5203
Fax Number : 910-323-3650
Authorized Official
Title or Position : PRACTICE ADMINISTRATOR
Name : MRS. TINA M. CASILLO
Credential :
Telephone Number : 910-323-5203
Provider Enumeration Date : 08/30/2007
Last Update Date : 02/11/2021

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