Provider Demographics
NPI:1043215643
Name:DIGESTIVE HEALTH SPECIALISTS PA
Entity Type:Organization
Organization Name:DIGESTIVE HEALTH SPECIALISTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:Y
Authorized Official - Last Name:TRADD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-822-9410
Mailing Address - Street 1:1070 N STONE ST
Mailing Address - Street 2:STE D
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-0824
Mailing Address - Country:US
Mailing Address - Phone:386-822-9410
Mailing Address - Fax:386-469-0045
Practice Address - Street 1:1070 N STONE ST
Practice Address - Street 2:STE D
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-0824
Practice Address - Country:US
Practice Address - Phone:386-822-9410
Practice Address - Fax:386-469-0045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36213174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
593256803OtherFEI #
FLAD145YMedicare PIN
593256803OtherFEI #
FL64582AMedicare PIN
FL53594AMedicare PIN
FL46793AMedicare PIN