MEDICARE: INNOVATIVE GASTROENTEROLOGY, INC

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

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

General Provider Information

NPI Number	:	1790233401
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE GASTROENTEROLOGY, INC

Provider Business Mailing Address
First Line	:	6210 SCOTT ST
Second Line	:	SUITE 216
City	:	PUNTA GORDA
State	:	FL
Zip	:	33950-3901
Country	:	US
Telephone Number	:	941-378-3871
Fax Number	:

Provider Business Practice Location Address
First Line	:	6210 SCOTT ST
Second Line	:	SUITE 216
City	:	PUNTA GORDA
State	:	FL
Zip	:	33950-3901
Country	:	US
Telephone Number	:	941-378-3871
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL BILLING MANAGER
Name	:	KOSONDRA GRANT
Credential	:
Telephone Number	:	770-485-1447

Provider Enumeration Date	:	09/12/2016
Last Update Date	:	09/12/2016

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