Provider Demographics
NPI:1992998975
Name:EAST COAST GASTROENTEROLOGY LLC
Entity type:Organization
Organization Name:EAST COAST GASTROENTEROLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-258-6333
Mailing Address - Street 1:PO BOX 62249
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2249
Mailing Address - Country:US
Mailing Address - Phone:301-583-7770
Mailing Address - Fax:301-583-9414
Practice Address - Street 1:1450 MERCANTILE LN
Practice Address - Street 2:SUITE 217
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5376
Practice Address - Country:US
Practice Address - Phone:301-583-7770
Practice Address - Fax:301-583-9414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD129080Medicare PIN
DC127708Medicare PIN