Healthcare Provider Details

I. General information

NPI: 1104510650
Provider Name (Legal Business Name): VSR PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2023
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 W IMBODEN DR
DECATUR IL
62521-5238
US

IV. Provider business mailing address

4200 CONESTOGA DR STE 102 PO BOX 178
SPRINGFIELD IL
62711-7937
US

V. Phone/Fax

Practice location:
  • Phone: 715-207-1134
  • Fax:
Mailing address:
  • Phone: 715-207-1134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: VENU M RANGU
Title or Position: PRESIDENT
Credential: MD
Phone: 715-387-9055