Provider Demographics
NPI:1831394766
Name:DIGESTIVE DISEASES CENTER
Entity type:Organization
Organization Name:DIGESTIVE DISEASES CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:WEDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-331-0233
Mailing Address - Street 1:2920 S MCINTYRE DR STE 310
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-4215
Mailing Address - Country:US
Mailing Address - Phone:812-331-0233
Mailing Address - Fax:812-331-0287
Practice Address - Street 1:2920 MCINTYRE DR STE 310
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4215
Practice Address - Country:US
Practice Address - Phone:812-331-0233
Practice Address - Fax:812-331-0287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031299A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200890860AMedicaid
IN100184520Medicaid
IN100184520Medicaid
INC87056Medicare UPIN