Provider Demographics
NPI:1194786566
Name:GASTROENTEROLOGY ASSOCIATES PC
Entity type:Organization
Organization Name:GASTROENTEROLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:COLIP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-255-3054
Mailing Address - Street 1:10000 SE MAIN ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2448
Mailing Address - Country:US
Mailing Address - Phone:503-255-3054
Mailing Address - Fax:503-255-7651
Practice Address - Street 1:10000 SE MAIN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2448
Practice Address - Country:US
Practice Address - Phone:503-255-3054
Practice Address - Fax:503-255-7651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11209174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORROOOOWCJTLMedicare ID - Type Unspecified