Provider Demographics
NPI:1932438272
Name:SOUTHEND GASTROENTEROLOGY ASSOCIATES PLLC
Entity Type:Organization
Organization Name:SOUTHEND GASTROENTEROLOGY ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:K
Authorized Official - Last Name:JAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-891-4000
Mailing Address - Street 1:2503 BUSH RIDGE DR
Mailing Address - Street 2:A
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-5885
Mailing Address - Country:US
Mailing Address - Phone:502-819-4000
Mailing Address - Fax:
Practice Address - Street 1:4402 CHURCHMAN AVE
Practice Address - Street 2:STE 408
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1190
Practice Address - Country:US
Practice Address - Phone:502-365-5140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-16
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000644156OtherANTHEM
IN201118680Medicaid
7956992OtherAETNA
KY7100101260Medicaid
KY50027327OtherPASSPORT
INM100063180Medicare PIN
IN201118680Medicaid