Provider Demographics
NPI:1447339767
Name:CAROLINA DIGESTIVE DISEASES, PA
Entity type:Organization
Organization Name:CAROLINA DIGESTIVE DISEASES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAZETT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-758-8181
Mailing Address - Street 1:704 WH SMITH BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834
Mailing Address - Country:US
Mailing Address - Phone:252-758-8181
Mailing Address - Fax:252-758-8182
Practice Address - Street 1:704 WH SMITH BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834
Practice Address - Country:US
Practice Address - Phone:252-758-8181
Practice Address - Fax:252-758-8182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NC174400000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5906998Medicaid
NC208487CMedicare PIN
NC5906998Medicaid