Provider Demographics
NPI:1295772861
Name:BAYFRONT DIGESTIVE DISEASE ASSOCIATES PC
Entity type:Organization
Organization Name:BAYFRONT DIGESTIVE DISEASE ASSOCIATES PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CASILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-456-7733
Mailing Address - Street 1:100 PEACH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1411
Mailing Address - Country:US
Mailing Address - Phone:814-456-7733
Mailing Address - Fax:814-456-7213
Practice Address - Street 1:100 PEACH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1411
Practice Address - Country:US
Practice Address - Phone:814-456-7733
Practice Address - Fax:814-456-7213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010182600013Medicaid
PAB185348OtherHIGHMARK BLUE SHIELD GRP
OH0609354Medicaid
OH0609354Medicaid
PA185348Medicare ID - Type UnspecifiedPA MEDICARE GROUP NUMBER
PA110013049Medicare ID - Type UnspecifiedRAILROAD MEDICARE GROUP #