MEDICARE: JCL GASTROENTEROLOGY, LLC

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	207RG0100X	Gastroenterology Physician

General Provider Information

NPI Number	:	1528292125
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JCL GASTROENTEROLOGY, LLC

Provider Business Mailing Address
First Line	:	PO BOX 9907
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85068-0907
Country	:	US
Telephone Number	:	623-580-5390
Fax Number	:

Provider Business Practice Location Address
First Line	:	9237 N. 3RD STREET
Second Line	:	SUITE 202
City	:	PHOENIX
State	:	AZ
Zip	:	85020-0000
Country	:	US
Telephone Number	:	623-580-5390
Fax Number	:	623-580-5397

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT
Name	:	GARY R. GROVER
Credential	:
Telephone Number	:	602-216-6680

Provider Enumeration Date	:	05/11/2009
Last Update Date	:	05/11/2009

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