Healthcare Provider Details

I. General information

NPI: 1831394766
Provider Name (Legal Business Name): DIGESTIVE DISEASES CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 MCINTYRE DR STE 310
BLOOMINGTON IN
47403-4215
US

IV. Provider business mailing address

2920 S MCINTYRE DR STE 310
BLOOMINGTON IN
47403-4215
US

V. Phone/Fax

Practice location:
  • Phone: 812-331-0233
  • Fax: 812-331-0287
Mailing address:
  • Phone: 812-331-0233
  • Fax: 812-331-0287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01031299A
License Number StateIN

VIII. Authorized Official

Name: DR. RICHARD A WEDDLE
Title or Position: PRESIDENT
Credential: MD
Phone: 812-331-0233