Provider Demographics
NPI:1043572563
Name:DIGESTIVE DISEASE CLINIC PC
Entity Type:Organization
Organization Name:DIGESTIVE DISEASE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOWAFAK
Authorized Official - Middle Name:A
Authorized Official - Last Name:ASBAHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-476-6100
Mailing Address - Street 1:18320 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152
Mailing Address - Country:US
Mailing Address - Phone:248-476-6100
Mailing Address - Fax:248-476-6452
Practice Address - Street 1:18320 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152
Practice Address - Country:US
Practice Address - Phone:248-476-6100
Practice Address - Fax:248-471-6452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-11
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301033455207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI102699892Medicaid
0826296Medicare PIN
B44672Medicare UPIN