Provider Demographics
NPI:1548462963
Name:ASHEBORO DIGESTIVE DISEASE CLINIC PA
Entity type:Organization
Organization Name:ASHEBORO DIGESTIVE DISEASE CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LESIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:MISENHEIMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-629-5989
Mailing Address - Street 1:548 GREENSBORO ST
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27203-5573
Mailing Address - Country:US
Mailing Address - Phone:336-629-5989
Mailing Address - Fax:336-629-9868
Practice Address - Street 1:548 GREENSBORO ST
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-5573
Practice Address - Country:US
Practice Address - Phone:336-629-5989
Practice Address - Fax:336-629-9868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8959547Medicaid
NC2331010Medicare ID - Type Unspecified