Healthcare Provider Details

I. General information

NPI: 1336319094
Provider Name (Legal Business Name): AMARESH VYDYANATHAN MD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2008
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 S MERCER AVE
BLOOMINGTON IL
61701-7107
US

IV. Provider business mailing address

1015 S MERCER AVE
BLOOMINGTON IL
61701-7107
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-4321
  • Fax: 309-661-4532
Mailing address:
  • Phone: 309-662-4321
  • Fax: 309-661-4532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number57.009044
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number036124700
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number036124700
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: