=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164528527
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR DIGESTIVE CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2006
-----------------------------------------------------
Last Update Date | 08/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5300 ELLIOTT DR
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48197
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-434-6262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5300 ELLIOTT DR
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48197
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-434-6262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | LANA COOPER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 734-528-1405
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367H00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiologist Assistant
-----------------------------------------------------
License Number | 4704111201
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367H00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiologist Assistant
-----------------------------------------------------
License Number | 4704204265
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 367H00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiologist Assistant
-----------------------------------------------------
License Number | 4704118315
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 81-6818
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------