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NPI Code Detail

MEDICARE: DR. MAITRAYEE SUNDARESAN VADALI MD

MEDICARE: DR. MAITRAYEE SUNDARESAN VADALI MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207RC0000XCardiovascular Disease Physician036102767IL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2P00157926OTHERILPALMETTO GBA INDIVIDUAL #
321622931OTHERIDBCBS GROUP #
4CI8250OTHERILPALMETTO GBA GROUP #

General Provider Information

NPI Number : 1013900851
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. MAITRAYEE SUNDARESAN VADALI MD
Provider Business Mailing Address
First Line : 12251 S 80TH AVE STE 1520
Second Line :
City : PALOS HEIGHTS
State : IL
Zip : 60463-1290
Country : US
Telephone Number : 708-923-4200
Fax Number : 708-923-4201
Provider Business Practice Location Address
First Line : 12251 S 80TH AVE STE 1520
Second Line :
City : PALOS HEIGHTS
State : IL
Zip : 60463-1290
Country : US
Telephone Number : 708-923-4200
Fax Number : 708-923-4201
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/26/2005
Last Update Date : 11/30/2023

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