Provider Demographics
NPI:1083988380
Name:SOUTHERN ILLINOIS ENDOSCOPY
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS ENDOSCOPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VASANTHA
Authorized Official - Middle Name:PERJE
Authorized Official - Last Name:PAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-355-0880
Mailing Address - Street 1:2810 FRANK SCOTT PARKWAY
Mailing Address - Street 2:SUITE 716
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-6802
Mailing Address - Country:US
Mailing Address - Phone:618-355-0880
Mailing Address - Fax:618-355-0881
Practice Address - Street 1:2810 FRANK SCOTT PARKWAY
Practice Address - Street 2:SUITE 716
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-6802
Practice Address - Country:US
Practice Address - Phone:618-355-0880
Practice Address - Fax:618-355-0881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.097852207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G48287Medicare UPIN