MEDICARE: PEDIATRIC GASTROENTEROLOGY, PC

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
1	2080P0206X	Pediatric Gastroenterology Physician	28542	AZ

General Provider Information

NPI Number	:	1487687117
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC GASTROENTEROLOGY, PC

Provider Business Mailing Address
First Line	:	PO BOX 43130
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85733-3130
Country	:	US
Telephone Number	:	520-722-3777
Fax Number	:	520-296-6624

Provider Business Practice Location Address
First Line	:	5295 E KNIGHT DR
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85712-2147
Country	:	US
Telephone Number	:	520-319-0313
Fax Number	:	520-319-0739

Authorized Official
Title or Position	:	PRESIDENT
Name	:	UWE BLECKER
Credential	:	MD
Telephone Number	:	520-319-0313

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	08/22/2020

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