Provider Demographics
NPI:1821245382
Name:SOUTHLAND GI MEDICAL CORPORATION A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SOUTHLAND GI MEDICAL CORPORATION A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SREENIVASA
Authorized Official - Middle Name:RAO
Authorized Official - Last Name:NAKKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-929-1177
Mailing Address - Street 1:949 CALHOUN PL
Mailing Address - Street 2:STE A
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4403
Mailing Address - Country:US
Mailing Address - Phone:951-929-1177
Mailing Address - Fax:951-765-9111
Practice Address - Street 1:25485 MEDICAL CENTER DR
Practice Address - Street 2:STE 104
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-6927
Practice Address - Country:US
Practice Address - Phone:951-304-3900
Practice Address - Fax:951-304-3901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-26
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty