Provider Demographics
NPI:1023387040
Name:SURIYA SASTRI, MDPC
Entity type:Organization
Organization Name:SURIYA SASTRI, MDPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SURIYA
Authorized Official - Middle Name:V
Authorized Official - Last Name:SASTRI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-325-8684
Mailing Address - Street 1:6900 MADISON STREET
Mailing Address - Street 2:SUITE - 102
Mailing Address - City:WILLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527
Mailing Address - Country:US
Mailing Address - Phone:630-325-8684
Mailing Address - Fax:630-325-2490
Practice Address - Street 1:6900 S MADISON ST
Practice Address - Street 2:SUITE 102
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-5510
Practice Address - Country:US
Practice Address - Phone:630-325-8684
Practice Address - Fax:630-325-2490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-20
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036068118207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036068118Medicaid
IL036068118Medicaid