Provider Demographics
NPI:1972758183
Name:DIGESTIVE DISEASE ASSOCIATES ENDOSCOPY SUITE, LLC
Entity type:Organization
Organization Name:DIGESTIVE DISEASE ASSOCIATES ENDOSCOPY SUITE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:DUNBAR
Authorized Official - Last Name:ILLICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-481-0315
Mailing Address - Street 1:687 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3612
Mailing Address - Country:US
Mailing Address - Phone:203-481-0315
Mailing Address - Fax:203-488-6945
Practice Address - Street 1:687 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3612
Practice Address - Country:US
Practice Address - Phone:203-481-0315
Practice Address - Fax:203-488-6945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-02
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0322261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT07C0001054OtherCCN CENTERS FOR MEDICARE AND MEDICAID SERVICES CERTIFICATION NUMBER