Provider Demographics
NPI:1184985475
Name:ADVANCED GASTROENTEROLOGY ASSOCIATES
Entity type:Organization
Organization Name:ADVANCED GASTROENTEROLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:AUTUMN
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-436-2906
Mailing Address - Street 1:4801 N BUTLER AVE
Mailing Address - Street 2:SUITE 13102
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6002
Mailing Address - Country:US
Mailing Address - Phone:505-436-2906
Mailing Address - Fax:505-436-2197
Practice Address - Street 1:4801 N BUTLER AVE
Practice Address - Street 2:SUITE 13102
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6002
Practice Address - Country:US
Practice Address - Phone:505-436-2906
Practice Address - Fax:505-436-2197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-03
Last Update Date:2013-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMDT4411OtherRR MCR
NM792536OtherAHCCCS
NM30177880Medicaid
NM30177880Medicaid