Basic Information
| Provider Information | |||||||||
| NPI: | 1093806374 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIGESTIVE HEALTHCARE ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8865 W 400 N #155 | ||||||||
| Address2: | |||||||||
| City: | MICHIGAN CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193624887 | ||||||||
| FaxNumber: | 2198722712 | ||||||||
| Practice Location | |||||||||
| Address1: | 8865 W 400 N #155 | ||||||||
| Address2: | |||||||||
| City: | MCIHGAN CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193624887 | ||||||||
| FaxNumber: | 2198722712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 05/31/2011 | ||||||||
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| AuthorizedOfficialLastName: | GILLEN | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING REPRESENTATIVE | ||||||||
| AuthorizedOfficialTelephone: | 2193624887 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 100209820 | 05 | IN | MEDICAID |