Basic Information
| Provider Information | |||||||||
| NPI: | 1063698900 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIGESTIVE CARE SPECIALIST, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1505 NORTHSIDE BLVD | ||||||||
| Address2: | |||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702272222 | ||||||||
| FaxNumber: | 7702272220 | ||||||||
| Practice Location | |||||||||
| Address1: | 1505 NORTHSIDE BLVD | ||||||||
| Address2: | |||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702272222 | ||||||||
| FaxNumber: | 7702272220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2008 | ||||||||
| LastUpdateDate: | 03/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | SINGH | ||||||||
| AuthorizedOfficialFirstName: | RANVIR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 7702272222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | 055299 | GA | N | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty | 207RG0100X | 055299 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 448878285C | 05 | GA | MEDICAID |