=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548308976
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KINSTON DIGESTIVE DISEASES PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 HARDEE RD SUITE 103B
-----------------------------------------------------
City | KINSTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-522-0285
-----------------------------------------------------
Fax | 252-523-4474
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 HARDEE RD SUITE 103B
-----------------------------------------------------
City | KINSTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-522-0285
-----------------------------------------------------
Fax | 252-523-4474
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. RICHARD JAMES KROEGER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 252-522-0285
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 27814
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------