Healthcare Provider Details

I. General information

NPI: 1689766131
Provider Name (Legal Business Name): U.P. DIGESTIVE DISEASE ASSOCIATES. P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 06/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 W FAIR AVE SUITE 135
MARQUETTE MI
49855-5408
US

IV. Provider business mailing address

1414 W FAIR AVE SUITE 135
MARQUETTE MI
49855-5408
US

V. Phone/Fax

Practice location:
  • Phone: 906-225-3880
  • Fax: 906-225-4523
Mailing address:
  • Phone: 906-225-3880
  • Fax: 906-225-4523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number526811
License Number StateMI

VIII. Authorized Official

Name: CHERYL A LIUBAKKA
Title or Position: PRACTICE ADMINISTRATOR
Credential: CPA
Phone: 906-225-3880