Provider Demographics
NPI:1235246240
Name:PREMIER GASTROENTEROLOGY PA
Entity type:Organization
Organization Name:PREMIER GASTROENTEROLOGY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MUHAMMED-RODWAN
Authorized Official - Middle Name:ALI
Authorized Official - Last Name:HIBA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-597-4000
Mailing Address - Street 1:12102 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-5514
Mailing Address - Country:US
Mailing Address - Phone:352-597-4000
Mailing Address - Fax:352-597-0550
Practice Address - Street 1:12102 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5514
Practice Address - Country:US
Practice Address - Phone:352-597-4000
Practice Address - Fax:352-597-0550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69833207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
100016261OtherRAILROAD MEDICARE
2987121OtherUHC
360846358OtherFIRST HEALTH
2593473OtherGHI
7130182OtherAETNA
2119601215701OtherBEECH ST
1003105OtherHUMANA
FL2579162-0Medicaid
49489OtherBCBS
2987121OtherUHC
2593473OtherGHI