=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720273741
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIGESTIVE DISEASE ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2007
-----------------------------------------------------
Last Update Date | 09/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 268 MONTAUK AVE
-----------------------------------------------------
City | NEW LONDON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06320-4712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-442-8553
-----------------------------------------------------
Fax | 860-447-3169
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 268 MONTAUK AVE
-----------------------------------------------------
City | NEW LONDON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-442-8553
-----------------------------------------------------
Fax | 860-447-3169
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ALAN JAY GREENWALD
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 860-442-8553
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 021951
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------