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General NPI Number Information
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NPI Number | 1144588773
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Entity Type | Organization
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Legal Business Name | DIGESTIVE ENDOSCOPY, PA
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Dates
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Enumeration Date | 05/02/2012
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Last Update Date | 05/02/2012
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Provider Practice Location Address
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Address Line | 17322 91ST AVE N
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City | MAPLE GROVE
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State | MN
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Zip | 55311-5403
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Country | US
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Telephone | 763-416-0399
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Fax | 763-416-0399
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Provider Business Mailing Address
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Address Line | 5970 ARBOUR AVE
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City | EDINA
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State | MN
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Zip | 55436-2521
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Country | US
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Telephone | 952-920-6638
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Fax | 612-725-2248
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. WILLIAM CHARLES DUANE JR.
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Credential | MD
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Telephone | 763-416-0399
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 19698
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License Number State | MN
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