=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356480578
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIGESTIVE DISEASE ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 01/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1224 MAIN ST
-----------------------------------------------------
City | BRANFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06405-3778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-481-0315
-----------------------------------------------------
Fax | 203-481-6788
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 687 MAIN ST
-----------------------------------------------------
City | BRANFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06405-3612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-481-7050
-----------------------------------------------------
Fax | 203-488-6945
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | CHRISTOPHER DUNBAR ILLICK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 203-481-0315
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------