Provider Demographics
NPI:1174551758
Name:ASC GI DIAGNOSTIC CENTER, LLC
Entity type:Organization
Organization Name:ASC GI DIAGNOSTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:ARCHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-322-5753
Mailing Address - Street 1:2084 NE PROFESSIONAL CT
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6077
Mailing Address - Country:US
Mailing Address - Phone:541-322-5753
Mailing Address - Fax:541-749-2130
Practice Address - Street 1:2084 NE PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6077
Practice Address - Country:US
Practice Address - Phone:541-322-5753
Practice Address - Fax:541-749-2130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR071580261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR006075Medicaid
OR134822Medicare ID - Type Unspecified