Provider Demographics
NPI:1629204979
Name:ADVANCED GASTROENTEROLOGY, PC
Entity type:Organization
Organization Name:ADVANCED GASTROENTEROLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SON
Authorized Official - Middle Name:T
Authorized Official - Last Name:DO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-576-5060
Mailing Address - Street 1:2101 NE 139TH ST STE 265
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-2311
Mailing Address - Country:US
Mailing Address - Phone:360-576-5060
Mailing Address - Fax:360-576-1133
Practice Address - Street 1:2101 NE 139TH ST STE 265
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2311
Practice Address - Country:US
Practice Address - Phone:360-576-5060
Practice Address - Fax:360-576-1133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-01
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602508382174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8856933Medicare PIN