Provider Demographics
NPI:1619900248
Name:CENTER FOR DIGESTIVE DISEASES PA
Entity Type:Organization
Organization Name:CENTER FOR DIGESTIVE DISEASES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SCHEDULE COORNIDATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:F
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-384-2016
Mailing Address - Street 1:PO BOX 20267
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-0267
Mailing Address - Country:US
Mailing Address - Phone:727-823-2188
Mailing Address - Fax:727-828-0723
Practice Address - Street 1:1609 PASADENA AVE S
Practice Address - Street 2:STE 3M
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33707-4563
Practice Address - Country:US
Practice Address - Phone:727-384-2016
Practice Address - Fax:727-343-3791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME48637207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL24038OtherBCBS
FLCL1357OtherRAILROAD MEDICARE
FL373745400Medicaid
FL24038Medicare PIN