Provider Demographics
NPI:1174356489
Name:SOUDER GASTRO
Entity type:Organization
Organization Name:SOUDER GASTRO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-697-2229
Mailing Address - Street 1:150 FRIENDSHIP RD
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:TN
Mailing Address - Zip Code:38355-8666
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 FRIENDSHIP RD
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:TN
Practice Address - Zip Code:38355-8666
Practice Address - Country:US
Practice Address - Phone:731-697-2229
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy