Provider Demographics
NPI:1447450804
Name:COLON & RECTAL DISEASE CENTER, INC.
Entity type:Organization
Organization Name:COLON & RECTAL DISEASE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAHENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-793-9835
Mailing Address - Street 1:10496 MONTGOMERY RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242-5220
Mailing Address - Country:US
Mailing Address - Phone:513-793-9835
Mailing Address - Fax:513-793-9837
Practice Address - Street 1:10496 MONTGOMERY RD
Practice Address - Street 2:SUITE 204
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242-5220
Practice Address - Country:US
Practice Address - Phone:513-793-9835
Practice Address - Fax:513-793-9837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHMA9242941Medicare PIN