Healthcare Provider Details

I. General information

NPI: 1245224286
Provider Name (Legal Business Name): TIPPECANOE ENDOSCOPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 11/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 BOARDMAN CANFIELD RD
YOUNGSTOWN OH
44512-4003
US

IV. Provider business mailing address

1210 BOARDMAN CANFIELD RD
YOUNGSTOWN OH
44512-4003
US

V. Phone/Fax

Practice location:
  • Phone: 330-726-0132
  • Fax: 330-726-2571
Mailing address:
  • Phone: 330-726-0132
  • Fax: 330-726-2571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number0009AS
License Number StateOH

VIII. Authorized Official

Name: YING K AMORN
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 330-726-0132