Provider Demographics
NPI:1962521476
Name:GASTROENTEROLOGY SPECIALISTS OF MARQUETTE, PLLC
Entity type:Organization
Organization Name:GASTROENTEROLOGY SPECIALISTS OF MARQUETTE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:STAHL,III
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-225-3680
Mailing Address - Street 1:2837 US HIGHWAY 41 W
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2252
Mailing Address - Country:US
Mailing Address - Phone:906-225-3964
Mailing Address - Fax:906-226-3875
Practice Address - Street 1:580 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2705
Practice Address - Country:US
Practice Address - Phone:906-225-3680
Practice Address - Fax:906-225-4815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301082866207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1005210961OtherBLUE CROSS BLUE SHIELD MI
MI0521096OtherBLUE CROSS BLUE SHIELD MI
MI4994550Medicaid
MIF61513Medicare UPIN
MI0P43050Medicare PIN
DN1827Medicare PIN