Healthcare Provider Details

I. General information

NPI: 1215925656
Provider Name (Legal Business Name): NAGESWARARAO VALLABHANENI MD PSYCHIATRIST
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 LEHMEN DR
CHESTER IL
62233-0031
US

IV. Provider business mailing address

12831 HICKORY WOODS DR
SAINT LOUIS MO
63131-1828
US

V. Phone/Fax

Practice location:
  • Phone: 618-826-4571
  • Fax: 618-826-3229
Mailing address:
  • Phone: 314-966-8746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: