Provider Demographics
NPI:1407944192
Name:SOUTHERN ILLINOIS VASCULAR SURGERY, PC
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS VASCULAR SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HANS
Authorized Official - Middle Name:HASSAN
Authorized Official - Last Name:MOOSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-233-2500
Mailing Address - Street 1:311 W LINCOLN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1902
Mailing Address - Country:US
Mailing Address - Phone:618-233-2500
Mailing Address - Fax:618-233-2520
Practice Address - Street 1:311 W LINCOLN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1902
Practice Address - Country:US
Practice Address - Phone:618-233-2500
Practice Address - Fax:618-233-2520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty