Basic Information
| Provider Information | |||||||||
| NPI: | 1619900248 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTER FOR DIGESTIVE DISEASES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 20267 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336220267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278232188 | ||||||||
| FaxNumber: | 7278280723 | ||||||||
| Practice Location | |||||||||
| Address1: | 1609 PASADENA AVE S | ||||||||
| Address2: | STE 3M | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337074563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273842016 | ||||||||
| FaxNumber: | 7273433791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 06/18/2009 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | SCHEDULE COORNIDATOR | ||||||||
| AuthorizedOfficialTelephone: | 7273842016 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | ME48637 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 24038 | 01 | FL | BCBS | OTHER | CL1357 | 01 | FL | RAILROAD MEDICARE | OTHER | 373745400 | 05 | FL | MEDICAID |