Basic Information
| Provider Information | |||||||||
| NPI: | 1679640353 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGESTIVE HEALTHCARE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5900 HILLANDALE DR STE 330 | ||||||||
| Address2: | |||||||||
| City: | LITHONIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300583892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708170224 | ||||||||
| FaxNumber: | 7708170228 | ||||||||
| Practice Location | |||||||||
| Address1: | 5900 HILLANDALE DR STE 330 | ||||||||
| Address2: | |||||||||
| City: | LITHONIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300583892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708170224 | ||||||||
| FaxNumber: | 7708170228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CONNELL | ||||||||
| AuthorizedOfficialFirstName: | KWAME | ||||||||
| AuthorizedOfficialMiddleName: | VIKRAM | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7708170224 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.