Provider Demographics
NPI:1396763330
Name:CONSULTANTS IN GASTROENTEROLOGY, SC
Entity type:Organization
Organization Name:CONSULTANTS IN GASTROENTEROLOGY, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:EFRUSY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:219-922-3040
Mailing Address - Street 1:701 SUPERIOR AVENUE
Mailing Address - Street 2:SUITE G
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321
Mailing Address - Country:US
Mailing Address - Phone:219-922-3041
Mailing Address - Fax:219-922-3048
Practice Address - Street 1:701 SUPERIOR AVE
Practice Address - Street 2:SUITE G
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-4037
Practice Address - Country:US
Practice Address - Phone:219-922-3041
Practice Address - Fax:219-922-3048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000882207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100202290AMedicaid
IN100202290AMedicaid
IL=========4632102Medicaid
IL211956Medicare PIN