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General NPI Number Information
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NPI Number | 1881964930
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Entity Type | Organization
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Legal Business Name | BOARDMAN GASTROENTEROLOGY GROUP, INC.
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Dates
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Enumeration Date | 01/06/2012
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Last Update Date | 01/06/2012
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Provider Practice Location Address
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Address Line | 1220 BOARDMAN CANFIELD RD
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City | YOUNGSTOWN
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State | OH
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Zip | 44512-4003
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Country | US
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Telephone | 330-726-0131
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Fax | 330-726-2571
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Provider Business Mailing Address
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Address Line | 1622 E MARKET ST
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City | WARREN
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State | OH
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Zip | 44483-6613
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Country | US
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Telephone | 330-399-7215
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Fax | 330-399-2411
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Authorized Official
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Title or Position | BILLING ADMINISTRATOR
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Name | MS. DENISE IRWIN
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Credential |
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Telephone | 330-399-7215
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 2068614
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License Number State | OH
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