Healthcare Provider Details

I. General information

NPI: 1376515064
Provider Name (Legal Business Name): MADHUSUDAN R MALLADI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 10/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1036 W STEPHENSON ST
FREEPORT IL
61032-4865
US

IV. Provider business mailing address

421 W EXCHANGE ST PO BOX 268
FREEPORT IL
61032-4030
US

V. Phone/Fax

Practice location:
  • Phone: 815-599-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036088380
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: