Provider Demographics
NPI:1538110713
Name:CENTER FOR DIGESTIVE HEALTH LLC
Entity Type:Organization
Organization Name:CENTER FOR DIGESTIVE HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-680-5565
Mailing Address - Street 1:PO BOX 3488
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-3488
Mailing Address - Country:US
Mailing Address - Phone:662-680-5565
Mailing Address - Fax:662-680-5654
Practice Address - Street 1:589 GARFIELD ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6301
Practice Address - Country:US
Practice Address - Phone:662-680-5565
Practice Address - Fax:662-680-5654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-13
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS25C0001058261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03208889Medicaid
MS490000057Medicare ID - Type Unspecified