Healthcare Provider Details

I. General information

NPI: 1194722942
Provider Name (Legal Business Name): SARAT YALAMANCHILI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date: 03/21/2006
Reactivation Date: 03/28/2006

III. Provider practice location address

1521 N CONVENT ST STE 101
BOURBONNAIS IL
60914-1469
US

IV. Provider business mailing address

1521 N CONVENT ST STE 101
BOURBONNAIS IL
60914-1469
US

V. Phone/Fax

Practice location:
  • Phone: 815-937-4500
  • Fax: 815-937-4777
Mailing address:
  • Phone: 815-937-4500
  • Fax: 815-937-4777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-094568
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: