Provider Demographics
NPI:1063596419
Name:COLORECTAL ASSOC INC
Entity type:Organization
Organization Name:COLORECTAL ASSOC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEET
Authorized Official - Middle Name:RAM
Authorized Official - Last Name:MEHTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-759-8545
Mailing Address - Street 1:16 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-2137
Mailing Address - Country:US
Mailing Address - Phone:330-759-8545
Mailing Address - Fax:330-759-8543
Practice Address - Street 1:16 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-2137
Practice Address - Country:US
Practice Address - Phone:330-759-8545
Practice Address - Fax:330-759-8543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35036259208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0965835Medicaid
OH0965835Medicaid