1174700421 NPI number — DIGESTIVE DISEASE ASSOCIATES PC

Table of content: (NPI 1174700421)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174700421 NPI number — DIGESTIVE DISEASE ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIGESTIVE DISEASE ASSOCIATES PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174700421
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
47 OBERY ST
Provider Second Line Business Mailing Address:
STE 201
Provider Business Mailing Address City Name:
PLYMOUTH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02360
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-747-1560
Provider Business Mailing Address Fax Number:
508-747-5155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
47 OBERY ST
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02360-2230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-747-1560
Provider Business Practice Location Address Fax Number:
508-747-5155
Provider Enumeration Date:
01/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RUSSO
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
508-747-1560

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3020835 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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