Healthcare Provider Details

I. General information

NPI: 1922454099
Provider Name (Legal Business Name): SUMMIT SUBHASH PANDAT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2016
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 SAINT ELIZABETH BLVD STE 1800
O FALLON IL
62269-1281
US

IV. Provider business mailing address

3 SAINT ELIZABETH BLVD STE 1800
O FALLON IL
62269-1281
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-6044
  • Fax: 618-233-5195
Mailing address:
  • Phone: 618-233-6044
  • Fax: 618-233-5195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036176457
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number036176457
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number300519
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: