Healthcare Provider Details

I. General information

NPI: 1194132662
Provider Name (Legal Business Name): KARTHIKEYAN VADAKANTHARAI PARAMESWARAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2014
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2166 MADISON AVE
GRANITE CITY IL
62040-4700
US

IV. Provider business mailing address

2166 MADISON AVE
GRANITE CITY IL
62040-4700
US

V. Phone/Fax

Practice location:
  • Phone: 618-219-3318
  • Fax: 618-452-3329
Mailing address:
  • Phone: 618-219-3318
  • Fax: 618-452-3329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036143017
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: