=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811211394
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIGESTIVE DISEASE CENTER OF VIRGINIA, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2010
-----------------------------------------------------
Last Update Date | 08/18/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4125 IRONBOUND RD SUITE 201
-----------------------------------------------------
City | WILLIAMSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23188-2666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-232-8769
-----------------------------------------------------
Fax | 757-232-8875
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5424 DISCOVERY PARK BLVD SUITE 203
-----------------------------------------------------
City | WILLIAMSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23188-2862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-232-8769
-----------------------------------------------------
Fax | 757-232-8875
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | RICHARD J HARTLE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 757-232-8769
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 0101049148
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------