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	:	1851336994
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	:	602-485-7475
Fax Number	:	602-485-7492

Provider Business Practice Location Address
First Line	:	18404 N TATUM BLVD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-1511
Country	:	US
Telephone Number	:	602-485-7475
Fax Number	:	602-485-7492

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	SHERI GRIFFIN
Credential	:
Telephone Number	:	602-485-7460

Provider Enumeration Date	:	06/20/2006
Last Update Date	:	12/03/2007

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