Basic Information
| Provider Information | |||||||||
| NPI: | 1679686505 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PERMIAN ENDOSCOPY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797615133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4323358300 | ||||||||
| FaxNumber: | 4323358330 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797615133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4323358300 | ||||||||
| FaxNumber: | 4323358330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 09/17/2007 | ||||||||
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| AuthorizedOfficialLastName: | VEMURU | ||||||||
| AuthorizedOfficialFirstName: | RAVI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4323358300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | P00081819 | 01 | TX | RAILROAD MEDICARE | OTHER | HH1599 | 01 | TX | BCBS | OTHER |