Basic Information
| Provider Information | |||||||||
| NPI: | 1457500308 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIGESTIVE SPECIALISTS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 999 BRUBAKER DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454293588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372934424 | ||||||||
| FaxNumber: | 9373953682 | ||||||||
| Practice Location | |||||||||
| Address1: | 1157 N MONROE DR STE 230 | ||||||||
| Address2: | |||||||||
| City: | XENIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453851699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372932169 | ||||||||
| FaxNumber: | 9373953682 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2008 | ||||||||
| LastUpdateDate: | 11/05/2008 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMIN ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 9372934424 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 2861587 | 05 | OH | MEDICAID |