Healthcare Provider Details

I. General information

NPI: 1063596419
Provider Name (Legal Business Name): COLORECTAL ASSOC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 04/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 COLONIAL DR
YOUNGSTOWN OH
44505-2137
US

IV. Provider business mailing address

16 COLONIAL DR
YOUNGSTOWN OH
44505-2137
US

V. Phone/Fax

Practice location:
  • Phone: 330-759-8545
  • Fax: 330-759-8543
Mailing address:
  • Phone: 330-759-8545
  • Fax: 330-759-8543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number35036259
License Number StateOH

VIII. Authorized Official

Name: DR. JEET RAM MEHTA
Title or Position: PRESIDENT
Credential: MD
Phone: 330-759-8545