Provider Demographics
NPI:1689766131
Name:U.P. DIGESTIVE DISEASE ASSOCIATES. P.C.
Entity Type:Organization
Organization Name:U.P. DIGESTIVE DISEASE ASSOCIATES. P.C.
Other - Org Name:SUPERIOR ENDOSCOPY CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:A
Authorized Official - Last Name:LIUBAKKA
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:906-225-3880
Mailing Address - Street 1:1414 W FAIR AVE
Mailing Address - Street 2:SUITE 135
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-5408
Mailing Address - Country:US
Mailing Address - Phone:906-225-3880
Mailing Address - Fax:906-225-4523
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:SUITE 135
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-5408
Practice Address - Country:US
Practice Address - Phone:906-225-3880
Practice Address - Fax:906-225-4523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI526811261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI430003148OtherRAILROAD MEDICARE
MI40371OtherBLUE CROSS FACILITY NUMBE
MI490E209940OtherBCBSM PIN NIMBER
MI430003148OtherRAILROAD MEDICARE