MEDICARE: DIGESTIVE HEALTH SPECIALISTS PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	ME36213	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	593256803	OTHER		FEI #

General Provider Information

NPI Number	:	1043215643
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIGESTIVE HEALTH SPECIALISTS PA

Provider Business Mailing Address
First Line	:	1070 N STONE ST
Second Line	:	STE D
City	:	DELAND
State	:	FL
Zip	:	32720-0824
Country	:	US
Telephone Number	:	386-822-9410
Fax Number	:	386-469-0045

Provider Business Practice Location Address
First Line	:	1070 N STONE ST
Second Line	:	STE D
City	:	DELAND
State	:	FL
Zip	:	32720-0824
Country	:	US
Telephone Number	:	386-822-9410
Fax Number	:	386-469-0045

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	MRS. FAITH Y TRADD
Credential	:
Telephone Number	:	386-822-9410

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	07/14/2008

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