Provider Demographics
NPI:1548285141
Name:SUBURBAN GASTROENTEROLOGY ASSOCIATES INC
Entity type:Organization
Organization Name:SUBURBAN GASTROENTEROLOGY ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-789-3510
Mailing Address - Street 1:1010 WEST CHESTER PIKE
Mailing Address - Street 2:STE 202
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-3442
Mailing Address - Country:US
Mailing Address - Phone:610-789-3510
Mailing Address - Fax:610-789-3591
Practice Address - Street 1:1010 WEST CHESTER PIKE
Practice Address - Street 2:STE 202
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-3442
Practice Address - Country:US
Practice Address - Phone:610-789-3510
Practice Address - Fax:610-789-3591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PACF6518OtherRAILROAD MEDICARE
PA078329002Medicaid
PA0000124192Medicare PIN