Provider Demographics
NPI:1770544843
Name:GASTROENTEROLOGY MEDICINE S.C.
Entity type:Organization
Organization Name:GASTROENTEROLOGY MEDICINE S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LIDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIBA
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:414-671-0121
Mailing Address - Street 1:3201 S 16TH ST
Mailing Address - Street 2:2015
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-4537
Mailing Address - Country:US
Mailing Address - Phone:414-671-0121
Mailing Address - Fax:414-671-6949
Practice Address - Street 1:3201 S 16TH ST
Practice Address - Street 2:2015
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4537
Practice Address - Country:US
Practice Address - Phone:414-671-0121
Practice Address - Fax:414-671-6949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI01301Medicare ID - Type Unspecified