Healthcare Provider Details

I. General information

NPI: 1023387040
Provider Name (Legal Business Name): SURIYA SASTRI, MDPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2011
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 S MADISON ST SUITE 102
WILLOWBROOK IL
60527-5510
US

IV. Provider business mailing address

6900 MADISON STREET SUITE - 102
WILLOWBROOK IL
60527
US

V. Phone/Fax

Practice location:
  • Phone: 630-325-8684
  • Fax: 630-325-2490
Mailing address:
  • Phone: 630-325-8684
  • Fax: 630-325-2490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036068118
License Number StateIL

VIII. Authorized Official

Name: DR. SURIYA V SASTRI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 630-325-8684