Provider Demographics
NPI:1417099029
Name:GASTROENTEROLOGY CONSULTANTS OF SW FL, PA
Entity type:Organization
Organization Name:GASTROENTEROLOGY CONSULTANTS OF SW FL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SURESH
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVAKULA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-482-2280
Mailing Address - Street 1:5050 MASON CORBIN CT
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-4541
Mailing Address - Country:US
Mailing Address - Phone:239-482-2280
Mailing Address - Fax:239-482-2281
Practice Address - Street 1:5050 MASON CORBIN CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-4541
Practice Address - Country:US
Practice Address - Phone:239-482-2280
Practice Address - Fax:239-482-2281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78992174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257130700Medicaid
FLH10808Medicare UPIN