=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295169217
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLESTON DIGESTIVE DISEASE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2013
-----------------------------------------------------
Last Update Date | 08/27/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2335 CHESTERFIELD AVE SUITE 103
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25304-1066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-552-9037
-----------------------------------------------------
Fax | 304-935-4825
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2335 CHESTERFIELD AVE SUITE 103
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25304-1066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-552-9037
-----------------------------------------------------
Fax | 304-935-4825
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | MRS. OLIVIA GARTON
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 304-932-7555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 20498
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------