Healthcare Provider Details

I. General information

NPI: 1174700421
Provider Name (Legal Business Name): DIGESTIVE DISEASE ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2008
Last Update Date: 11/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 OBERY ST STE 201
PLYMOUTH MA
02360-2230
US

IV. Provider business mailing address

47 OBERY ST STE 201
PLYMOUTH MA
02360
US

V. Phone/Fax

Practice location:
  • Phone: 508-747-1560
  • Fax: 508-747-5155
Mailing address:
  • Phone: 508-747-1560
  • Fax: 508-747-5155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JONATHAN M RUSSO
Title or Position: PRESIDENT
Credential: MD
Phone: 508-747-1560