Basic Information
| Provider Information | |||||||||
| NPI: | 1578762811 | ||||||||
| 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: | 9375347330 | ||||||||
| FaxNumber: | 9372972208 | ||||||||
| Practice Location | |||||||||
| Address1: | 3220 BEAVER VU DR | ||||||||
| Address2: | |||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454346400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375347330 | ||||||||
| FaxNumber: | 9372972208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2007 | ||||||||
| LastUpdateDate: | 01/21/2014 | ||||||||
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| AuthorizedOfficialLastName: | JIT | ||||||||
| AuthorizedOfficialFirstName: | RAJKAMAL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9373962602 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 | 2861603 | 05 | OH | MEDICAID |