Healthcare Provider Details

I. General information

NPI: 1548366263
Provider Name (Legal Business Name): NARSIMHA R MUDDASANI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N 8TH ST
EAST SAINT LOUIS IL
62201-2989
US

IV. Provider business mailing address

2120 MADISON AVE SUITE 406
GRANITE CITY IL
62040-4744
US

V. Phone/Fax

Practice location:
  • Phone: 618-271-0130
  • Fax: 618-271-6325
Mailing address:
  • Phone: 618-877-1008
  • Fax: 618-877-1512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number105499
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036089128
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: