MEDICARE: SPECIALIST IN GASTROENTEROLOGY

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	R4F99	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	000012657	OTHER	MO	MEDICARE
3	CG0207	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	31998	OTHER		GHP

General Provider Information

NPI Number	:	1669523270
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPECIALIST IN GASTROENTEROLOGY

Provider Business Mailing Address
First Line	:	11525 OLDE CABIN RD
Second Line	:
City	:	CREVE COEUR
State	:	MO
Zip	:	63141-7146
Country	:	US
Telephone Number	:	314-997-0554
Fax Number	:	314-997-5086

Provider Business Practice Location Address
First Line	:	11525 OLDE CABIN RD
Second Line	:
City	:	CREVE COEUR
State	:	MO
Zip	:	63141-7146
Country	:	US
Telephone Number	:	314-997-0554
Fax Number	:	314-997-5086

Authorized Official
Title or Position	:	OFFICE ADMINISTRATOR
Name	:	MRS. PAULA D WILLIS
Credential	:
Telephone Number	:	314-997-0554

Provider Enumeration Date	:	01/12/2007
Last Update Date	:	04/25/2008

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Directions to “SPECIALIST IN GASTROENTEROLOGY ” Practice Location

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