Basic Information
| Provider Information | |||||||||
| NPI: | 1629462171 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED DIGESTIVE CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14010 SMOKETOWN RD | ||||||||
| Address2: | SUITE 117 | ||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221924722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035800181 | ||||||||
| FaxNumber: | 7038978763 | ||||||||
| Practice Location | |||||||||
| Address1: | 14010 SMOKETOWN RD | ||||||||
| Address2: | SUITE 117 | ||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035800181 | ||||||||
| FaxNumber: | 7038978763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2015 | ||||||||
| LastUpdateDate: | 07/18/2018 | ||||||||
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| AuthorizedOfficialLastName: | JOSOVITZ | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7035800181 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207ZP0105X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
No ID Information.