Provider Demographics
NPI:1093824872
Name:DIGESTIVE CARE OF EVANSVILLE PC
Entity Type:Organization
Organization Name:DIGESTIVE CARE OF EVANSVILLE PC
Other - Org Name:GASTROINTESTINAL ENDOSCOPY CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BUTCH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORS
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:812-477-6103
Mailing Address - Street 1:801 SAINT MARYS DR
Mailing Address - Street 2:SUITE 110 W
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-0511
Mailing Address - Country:US
Mailing Address - Phone:812-477-6103
Mailing Address - Fax:812-477-4697
Practice Address - Street 1:801 SAINT MARYS DR
Practice Address - Street 2:SUITE 110 W
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0511
Practice Address - Country:US
Practice Address - Phone:812-477-6103
Practice Address - Fax:812-477-4697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05-005820-1261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100274390AMedicaid
INZE0260Medicare ID - Type Unspecified