Basic Information
| Provider Information | |||||||||
| NPI: | 1124052444 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA DIGESTIVE HEALTH ASSOCIATES, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 603345 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282603345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043727974 | ||||||||
| FaxNumber: | 7043728201 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 BILLINGSLEY ROAD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043727974 | ||||||||
| FaxNumber: | 7043728201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 11/10/2017 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7043727974 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 40474 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 7901569 | 05 | NC | MEDICAID |