Basic Information
| Provider Information | |||||||||
| NPI: | 1194864504 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTER FOR DIGESTIVE HEALTH AND NUTRITION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 CHERRINGTON PARKWAY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MOON TOWNSHIP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151084305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4122621000 | ||||||||
| FaxNumber: | 4122624607 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 CHERRINGTON PARKWAY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MOON TOWNSHIP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151084305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4122621000 | ||||||||
| FaxNumber: | 4122624607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 02/09/2017 | ||||||||
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| AuthorizedOfficialLastName: | STINE | ||||||||
| AuthorizedOfficialFirstName: | LESTER | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4122621000 | ||||||||
| 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 | 207RG0100X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 1007728510005 | 05 | PA | MEDICAID |