Basic Information
| Provider Information | |||||||||
| NPI: | 1295772861 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAYFRONT DIGESTIVE DISEASE ASSOCIATES PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BAYFRONT DIGESTIVE DISEASE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PEACH ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165071411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144567733 | ||||||||
| FaxNumber: | 8144567213 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 PEACH ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165071411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144567733 | ||||||||
| FaxNumber: | 8144567213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 11/13/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CASILLO | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8144567733 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 0010182600013 | 05 | PA | MEDICAID | B185348 | 01 | PA | HIGHMARK BLUE SHIELD GRP | OTHER | 0609354 | 05 | OH | MEDICAID |