Provider Demographics
NPI:1124179171
Name:GASTROENTEROLOGY OF CANTON INC
Entity type:Organization
Organization Name:GASTROENTEROLOGY OF CANTON INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHARI
Authorized Official - Middle Name:
Authorized Official - Last Name:TOWNSEND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-492-6662
Mailing Address - Street 1:4124 MUNSON ST NW
Mailing Address - Street 2:SUITE A
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2979
Mailing Address - Country:US
Mailing Address - Phone:330-492-6662
Mailing Address - Fax:330-492-6918
Practice Address - Street 1:4124 MUNSON ST NW
Practice Address - Street 2:SUITE A
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2979
Practice Address - Country:US
Practice Address - Phone:330-492-6662
Practice Address - Fax:330-492-6918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35046973207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH100000769OtherRAILROAD MEDICARE
OH0559819Medicaid
OH000000137194OtherANTHEM
OH735536OtherBUCKEYE COMMUNITY
OH=========002OtherCHAMPUS
OH=========027OtherCARESOURCE
OH=========00OtherWORKERS COMPENSATION
OH100000769OtherRAILROAD MEDICARE