Provider Demographics
NPI:1447271515
Name:DIGESTIVE DISEASES & CLINICAL NUTRITION CENTER, PC
Entity type:Organization
Organization Name:DIGESTIVE DISEASES & CLINICAL NUTRITION CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GASTROENTEROLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANNAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-720-5130
Mailing Address - Street 1:1345 WILLOWDALE CT STE A
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-4736
Mailing Address - Country:US
Mailing Address - Phone:810-720-5130
Mailing Address - Fax:810-720-4661
Practice Address - Street 1:1345 WILLOWDALE CT STE A
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-4736
Practice Address - Country:US
Practice Address - Phone:810-720-5130
Practice Address - Fax:810-720-4661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISM010585207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF76188Medicare UPIN
MI0N99460Medicare ID - Type Unspecified