Basic Information
| Provider Information | |||||||||
| NPI: | 1093824872 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGESTIVE CARE OF EVANSVILLE PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GASTROINTESTINAL ENDOSCOPY CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 SAINT MARYS DR | ||||||||
| Address2: | SUITE 110 W | ||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477140511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124776103 | ||||||||
| FaxNumber: | 8124774697 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 SAINT MARYS DR | ||||||||
| Address2: | SUITE 110 W | ||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477140511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124776103 | ||||||||
| FaxNumber: | 8124774697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 03/12/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MOORS | ||||||||
| AuthorizedOfficialFirstName: | BUTCH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8124776103 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 05-005820-1 | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 100274390A | 05 | IN | MEDICAID |