Provider Demographics
NPI:1053505511
Name:DIGESTIVE DISEASE CENTER OF CENTRAL NEW YORK, LLC
Entity Type:Organization
Organization Name:DIGESTIVE DISEASE CENTER OF CENTRAL NEW YORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KEEGAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN MSN
Authorized Official - Phone:315-410-7400
Mailing Address - Street 1:5112 W TAFT RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-4868
Mailing Address - Country:US
Mailing Address - Phone:315-410-7400
Mailing Address - Fax:315-458-4183
Practice Address - Street 1:5112 W TAFT RD
Practice Address - Street 2:SUITE E
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-4868
Practice Address - Country:US
Practice Address - Phone:315-410-7400
Practice Address - Fax:315-458-4183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02966690Medicaid
NYBA1440Medicare PIN