Basic Information
| Provider Information | |||||||||
| NPI: | 1497727119 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGESTIVE ENDOSCOPY CENTER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DIGESTIVE ENDOSCOPY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1A BURTON HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372156187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152403720 | ||||||||
| FaxNumber: | 6152341720 | ||||||||
| Practice Location | |||||||||
| Address1: | 5697 SHULL RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | HUBER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454241203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375347330 | ||||||||
| FaxNumber: | 9372972208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 05/10/2022 | ||||||||
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| AuthorizedOfficialLastName: | SNODGRASS | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6156651283 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 2017856 | 05 | OH | MEDICAID | 1211AS | 01 | OH | STATE LICENSE | OTHER |