Provider Demographics
NPI:1881964930
Name:BOARDMAN GASTROENTEROLOGY GROUP, INC.
Entity type:Organization
Organization Name:BOARDMAN GASTROENTEROLOGY GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:IRWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-399-7215
Mailing Address - Street 1:1622 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-6613
Mailing Address - Country:US
Mailing Address - Phone:330-399-7215
Mailing Address - Fax:330-399-2411
Practice Address - Street 1:1220 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-4003
Practice Address - Country:US
Practice Address - Phone:330-726-0131
Practice Address - Fax:330-726-2571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2068614207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty