Provider Demographics
NPI:1164528527
Name:CENTER FOR DIGESTIVE CARE LLC
Entity Type:Organization
Organization Name:CENTER FOR DIGESTIVE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LANA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-528-1405
Mailing Address - Street 1:5300 ELLIOTT DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197
Mailing Address - Country:US
Mailing Address - Phone:734-434-6262
Mailing Address - Fax:
Practice Address - Street 1:5300 ELLIOTT DR
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197
Practice Address - Country:US
Practice Address - Phone:734-434-6262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI81-6818261QA1903X, 261QA1903X
MI4704111201367H00000X
MI4704204265367H00000X, 367H00000X
MI4704118315367H00000X, 367H00000X
MI4704174508367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Multi-Specialty
No367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI40378OtherBCBS FACILITY NUMBER
MI23C0001056OtherMEDICARE SUPPLIER #
MIB0109OtherBCN NUMBER
MIP01162164OtherMEDICARE RAILROAD
MIB0109OtherBCN
MIB0109OtherBCN
MIB0109OtherBCN NUMBER