Provider Demographics
NPI:1770813164
Name:DIGESTIVE & LIVER CLINIC, PLLC.
Entity type:Organization
Organization Name:DIGESTIVE & LIVER CLINIC, PLLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ASHOK
Authorized Official - Middle Name:
Authorized Official - Last Name:KANTHAWAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-877-1575
Mailing Address - Street 1:1360 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-1615
Mailing Address - Country:US
Mailing Address - Phone:606-877-1575
Mailing Address - Fax:606-877-1582
Practice Address - Street 1:1360 W 5TH ST
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-1615
Practice Address - Country:US
Practice Address - Phone:606-877-1575
Practice Address - Fax:606-877-1582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-06
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37920207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000654360OtherANTHEM
KYC23095OtherCHI
KY50008556OtherPASSPORT ADVANTAGE
KY614933100OtherBLACK LUNG
KY7100112810Medicaid
KY50008556OtherPASSPORT ADVANTAGE