Provider Demographics
NPI:1407960107
Name:DIGESTIVE DISEASE MEDICAL CONSULTANTS, PC
Entity Type:Organization
Organization Name:DIGESTIVE DISEASE MEDICAL CONSULTANTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:CORT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-561-9020
Mailing Address - Street 1:200 BREVCO PLZ
Mailing Address - Street 2:SUITE 208
Mailing Address - City:LAKE ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-2949
Mailing Address - Country:US
Mailing Address - Phone:636-561-9020
Mailing Address - Fax:636-561-6208
Practice Address - Street 1:200 BREVCO PLZ
Practice Address - Street 2:SUITE 208
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-2949
Practice Address - Country:US
Practice Address - Phone:636-561-9020
Practice Address - Fax:636-561-6208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOCC9057OtherRAILROAD MEDICARE GROUP #
MO502983109Medicaid
MO502983109Medicaid