Provider Demographics
NPI:1598334252
Name:MIDWEST ENDOSCOPY ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:MIDWEST ENDOSCOPY ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:HORACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-973-8740
Mailing Address - Street 1:325 W LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1921
Mailing Address - Country:US
Mailing Address - Phone:618-235-2299
Mailing Address - Fax:
Practice Address - Street 1:4224 LINCOLNSHIRE DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2156
Practice Address - Country:US
Practice Address - Phone:314-724-1348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty