Provider Demographics
NPI:1538367818
Name:ADULT & PEDIATRIC GASTROENTEROLOGY MEDICAL CENTER
Entity type:Organization
Organization Name:ADULT & PEDIATRIC GASTROENTEROLOGY MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:C G
Authorized Official - Last Name:MARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-736-8228
Mailing Address - Street 1:111 DEERWOOD RD
Mailing Address - Street 2:SUITE 168
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-4409
Mailing Address - Country:US
Mailing Address - Phone:925-736-8228
Mailing Address - Fax:925-736-8882
Practice Address - Street 1:111 DEERWOOD RD
Practice Address - Street 2:SUITE 168
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-4409
Practice Address - Country:US
Practice Address - Phone:925-736-8228
Practice Address - Fax:925-736-8882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-06
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83524207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty