Provider Demographics
NPI:1962445288
Name:GASTROENTEROLOGY HEPATOLOGY AND ENDOSCOPY PLLC
Entity Type:Organization
Organization Name:GASTROENTEROLOGY HEPATOLOGY AND ENDOSCOPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VANDANA
Authorized Official - Middle Name:
Authorized Official - Last Name:VEDULA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-779-5277
Mailing Address - Street 1:411 W BROADWAY
Mailing Address - Street 2:STE A
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48828
Mailing Address - Country:US
Mailing Address - Phone:989-779-5277
Mailing Address - Fax:989-779-5278
Practice Address - Street 1:411 W BROADWAY
Practice Address - Street 2:STE A
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48828
Practice Address - Country:US
Practice Address - Phone:989-779-5277
Practice Address - Fax:989-779-5278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079152207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H76348Medicare UPIN