Provider Demographics
NPI:1144588773
Name:DIGESTIVE ENDOSCOPY, PA
Entity Type:Organization
Organization Name:DIGESTIVE ENDOSCOPY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:DUANE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:763-416-0399
Mailing Address - Street 1:5970 ARBOUR AVE
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55436-2521
Mailing Address - Country:US
Mailing Address - Phone:952-920-6638
Mailing Address - Fax:612-725-2248
Practice Address - Street 1:17322 91ST AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-5403
Practice Address - Country:US
Practice Address - Phone:763-416-0399
Practice Address - Fax:763-416-0399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19698207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN255716900Medicaid
MN1033127964OtherNPI 1