Provider Demographics
NPI:1699797266
Name:BAY AREA GASTROINTESTINAL ENDOSCOPY AND LIVER SPECIALISTS LLC
Entity type:Organization
Organization Name:BAY AREA GASTROINTESTINAL ENDOSCOPY AND LIVER SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JODY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BERNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-631-0915
Mailing Address - Street 1:1305 S FORT HARRISON AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-3301
Mailing Address - Country:US
Mailing Address - Phone:727-631-0915
Mailing Address - Fax:727-631-0916
Practice Address - Street 1:1305 S FORT HARRISON AVE
Practice Address - Street 2:SUITE E
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3301
Practice Address - Country:US
Practice Address - Phone:727-631-0915
Practice Address - Fax:727-631-0916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64901174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374224500Medicaid
FLK8859Medicare PIN
FLF67912Medicare UPIN