=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619790821
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEXAS DIGESTIVE DISEASE CONSULTANTS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2024
-----------------------------------------------------
Last Update Date | 11/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 115 KILDAIRE PARK DR STE 201
-----------------------------------------------------
City | CARY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27518-8144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-816-4948
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 206239
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75320-6239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | KRISTINA KAY LOWERY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-930-3077
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------