Healthcare Provider Details

I. General information

NPI: 1366419210
Provider Name (Legal Business Name): BALAVITTAL VARANASI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: B.VITTAL VARANASI M.D.

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 01/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

936 M L KING DR
CENTRALIA IL
62801-3058
US

IV. Provider business mailing address

936 M L KING DR
CENTRALIA IL
62801-3058
US

V. Phone/Fax

Practice location:
  • Phone: 618-532-6439
  • Fax: 618-532-1549
Mailing address:
  • Phone: 618-532-6439
  • Fax: 618-532-1549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-085451
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: