Provider Demographics
NPI:1295169217
Name:CHARLESTON DIGESTIVE DISEASE, INC.
Entity type:Organization
Organization Name:CHARLESTON DIGESTIVE DISEASE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:OLIVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GARTON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:304-932-7555
Mailing Address - Street 1:2335 CHESTERFIELD AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1066
Mailing Address - Country:US
Mailing Address - Phone:304-552-9037
Mailing Address - Fax:304-935-4825
Practice Address - Street 1:2335 CHESTERFIELD AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1066
Practice Address - Country:US
Practice Address - Phone:304-552-9037
Practice Address - Fax:304-935-4825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20498207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVF99406Medicare UPIN