Healthcare Provider Details

I. General information

NPI: 1295847317
Provider Name (Legal Business Name): DIGESTIVE HEALTH & ENDOSCOPY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 N EASTOWN RD
LIMA OH
45807-2214
US

IV. Provider business mailing address

375 N EASTOWN RD
LIMA OH
45807
US

V. Phone/Fax

Practice location:
  • Phone: 419-228-3500
  • Fax: 419-879-6872
Mailing address:
  • Phone: 419-228-3500
  • Fax: 419-879-5142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number0802AS
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2721273
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer
# 2
Identifier000000513356
Identifier TypeOTHER
Identifier StateOH
Identifier IssuerANTHEM

VIII. Authorized Official

Name: ABDULLA TAJA
Title or Position: PRESIDENT
Credential: MD
Phone: 419-228-3500