Basic Information
| Provider Information | |||||||||
| NPI: | 1770556532 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIGESTIVE SPECIALISTS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4340 CLYO RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454597000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375347330 | ||||||||
| FaxNumber: | 9372972208 | ||||||||
| Practice Location | |||||||||
| Address1: | 4340 CLYO RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454597000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375347330 | ||||||||
| FaxNumber: | 9372972208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 01/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | SERVIS | ||||||||
| AuthorizedOfficialFirstName: | JOAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 9373962602 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/14/2020 | ||||||||
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 | 2248544 | 05 | OH | MEDICAID |