Provider Demographics
NPI:1285707885
Name:COMMONWEALTH GASTROENTEROLOGY ASSOCIATES, PLLC
Entity type:Organization
Organization Name:COMMONWEALTH GASTROENTEROLOGY ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:KELLER
Authorized Official - Last Name:STADIG
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, CMPE
Authorized Official - Phone:859-967-2055
Mailing Address - Street 1:177 BURT RD
Mailing Address - Street 2:BURT ROAD MEDICAL CLINIC
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-2410
Mailing Address - Country:US
Mailing Address - Phone:859-967-2055
Mailing Address - Fax:859-278-8488
Practice Address - Street 1:177 BURT RD
Practice Address - Street 2:BURT ROAD MEDICAL CLINIC
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2410
Practice Address - Country:US
Practice Address - Phone:859-967-2055
Practice Address - Fax:859-278-8488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65930695Medicaid
KY65930695Medicaid