NPIMap

Organization Active NPI

Gastroenterology Clinic, a Professional Medical Corporation

  • Gastroenterology Physician
  • Monroe, LA
National Provider Identifier
1366442642
Registry record updated Jun 2, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Gastroenterology PhysicianTaxonomy code 207RG0100X
Legal business name
GASTROENTEROLOGY CLINIC, A PROFESSIONAL MEDICAL CORPORATION
Practice address
611 Grammont St
Monroe, LA 71201-7516
Phone
(318) 325-2634
Fax
(318) 812-1205
NPI assigned
Jul 28, 2005
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 2, 2026

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Andrew W. Waldo
Title
Administrator
Phone
(318) 325-2634

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Gastroenterology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207RG0100X LA Primary

Addresses

Primary practice location

611 Grammont St
Monroe, LA 71201-7516

Mailing address

611 Grammont St
Monroe, LA 71201-7516
Phone (318) 325-2634

Other identifiers 2

IdentifierTypeStateIssuer
23704OtherBLUE CROSS OF LOUISIANA
1798240MedicaidLA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in LA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050201000943 LA Part B Supplier - Clinic/Group Practice 9234180803 Receives reassigned benefits from 14 practitioners
Practice locations: West Monroe, LA; Ruston, LA; Monroe, LA

National Provider Directory

National Provider Directory

Locations

411 E Vaughn Ave
Ruston, LA 71270
Phone (318) 232-7080

102 Thomas Rd
Ste 114
West Monroe, LA 71291
Phone (318) 812-3303

6812 Crumpler Blvd
Ste 205B
Olive Branch, MS 38654

Practitioners & affiliated clinicians

Practitioners 15

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 15

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1122508800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1780358400000",
    "number": "1366442642",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "611 GRAMMONT ST",
            "city": "MONROE",
            "state": "LA",
            "postal_code": "712017516",
            "telephone_number": "318-325-2634",
            "fax_number": "318-812-1205"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "611 GRAMMONT ST",
            "city": "MONROE",
            "state": "LA",
            "postal_code": "712017516",
            "telephone_number": "318-325-2634",
            "fax_number": "318-812-1205"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GASTROENTEROLOGY CLINIC, A PROFESSIONAL MEDICAL CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-07-28",
        "last_updated": "2026-06-02",
        "certification_date": "2026-06-02",
        "status": "A",
        "authorized_official_last_name": "WALDO",
        "authorized_official_first_name": "ANDREW",
        "authorized_official_middle_name": "W.",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "318-325-2634",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207RG0100X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine, Gastroenterology",
            "state": "LA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS OF LOUISIANA",
            "identifier": "23704",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1798240",
            "state": "LA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Monroe, LA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 2, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.