Provider Demographics
NPI:1861506545
Name:JACKSONVILLE DIGESTIVE DISEASES CLINIC PA
Entity Type:Organization
Organization Name:JACKSONVILLE DIGESTIVE DISEASES CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORP SEC
Authorized Official - Prefix:MRS
Authorized Official - First Name:CLARITA
Authorized Official - Middle Name:Q
Authorized Official - Last Name:ISSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-577-1444
Mailing Address - Street 1:224 MEMORIAL DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546
Mailing Address - Country:US
Mailing Address - Phone:910-577-1444
Mailing Address - Fax:910-577-1001
Practice Address - Street 1:224 MEMORIAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546
Practice Address - Country:US
Practice Address - Phone:910-577-1444
Practice Address - Fax:910-577-1001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22581207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC45475OtherBC
NC8945475Medicaid
C85562Medicare UPIN
NC201988Medicare PIN