=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912903287
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIGESTIVE CARE CONSULTANTS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2005
-----------------------------------------------------
Last Update Date | 11/03/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8775 NORWIN AVENUE
-----------------------------------------------------
City | NORTH HUNTINGDON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15642-2718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-864-0503
-----------------------------------------------------
Fax | 724-864-0535
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 585 RUGH STREET SUITE 202
-----------------------------------------------------
City | GREENSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15601-5667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-838-1534
-----------------------------------------------------
Fax | 724-838-1536
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BALU SHETTY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 724-864-0503
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 077567
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------