Healthcare Provider Details

I. General information

NPI: 1649321183
Provider Name (Legal Business Name): VENTRAPRAGADA S MOHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 09/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 W LINCOLN ST STE 300
BELLEVILLE IL
62220-1900
US

IV. Provider business mailing address

340 W LINCOLN ST 300
BELLEVILLE IL
62220-1900
US

V. Phone/Fax

Practice location:
  • Phone: 618-235-4883
  • Fax: 618-235-9573
Mailing address:
  • Phone: 618-235-4883
  • Fax: 618-235-9573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number36056737
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number36056737
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35338
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number36056737
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: