Provider Demographics
NPI:1104895911
Name:CONSULTATIVE GASTROENTEROLGY, PA
Entity type:Organization
Organization Name:CONSULTATIVE GASTROENTEROLGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:M
Authorized Official - Last Name:LUND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-224-1692
Mailing Address - Street 1:118 MONTGOMERY DR
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-3334
Mailing Address - Country:US
Mailing Address - Phone:864-224-1692
Mailing Address - Fax:864-224-0103
Practice Address - Street 1:118 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-3334
Practice Address - Country:US
Practice Address - Phone:864-224-1692
Practice Address - Fax:864-224-0103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA3736Medicaid
SCPA3736Medicaid