Provider Demographics
NPI:1053431924
Name:GASTROENTEROLOGISTS CONSULTANTS OF JASPER, PC
Entity type:Organization
Organization Name:GASTROENTEROLOGISTS CONSULTANTS OF JASPER, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:DAVILA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-295-9630
Mailing Address - Street 1:PO BOX 391
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35502-0391
Mailing Address - Country:US
Mailing Address - Phone:205-295-9630
Mailing Address - Fax:205-295-9362
Practice Address - Street 1:3400 HIGHWAY 78 E
Practice Address - Street 2:MEDICAL ARTS TOWER SUITE 504
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-8907
Practice Address - Country:US
Practice Address - Phone:205-295-9630
Practice Address - Fax:205-296-9362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-01
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL25227207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051553611DAVMedicaid
AL515-15424OtherBSBC
AL515-15424OtherBSBC
ALH28325Medicare UPIN