Provider Demographics
NPI:1124075627
Name:CORVALLIS GASTROENTEROLOGY PC
Entity type:Organization
Organization Name:CORVALLIS GASTROENTEROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SURINDER
Authorized Official - Middle Name:MOHAN
Authorized Official - Last Name:VASDEV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-768-6116
Mailing Address - Street 1:3521 NW SAMARITAN DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-4744
Mailing Address - Country:US
Mailing Address - Phone:541-768-6119
Mailing Address - Fax:541-768-6120
Practice Address - Street 1:3521 NW SAMARITAN DR
Practice Address - Street 2:SUITE 101
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-4744
Practice Address - Country:US
Practice Address - Phone:541-768-6119
Practice Address - Fax:541-768-6120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR240038Medicaid
OR112083Medicare PIN