Healthcare Provider Details

I. General information

NPI: 1427034917
Provider Name (Legal Business Name): JAYASIRI RAVINATH FERNANDO
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 W LINCOLN AVE
CHARLESTON IL
61920-2413
US

IV. Provider business mailing address

907 W LINCOLN AVE PO BOX 770
CHARLESTON IL
61920-2413
US

V. Phone/Fax

Practice location:
  • Phone: 217-345-2100
  • Fax: 217-345-8366
Mailing address:
  • Phone: 217-345-2100
  • Fax: 217-345-8366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: