Healthcare Provider Details

I. General information

NPI: 1417190216
Provider Name (Legal Business Name): VARATHASEELAN MUTHULINGAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 12/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S 14TH ST
HERRIN IL
62948-3631
US

IV. Provider business mailing address

P O BOX 1105
INDIANAPOLIS IN
46206-1105
US

V. Phone/Fax

Practice location:
  • Phone: 618-942-2171
  • Fax: 618-351-4919
Mailing address:
  • Phone: 618-549-5361
  • Fax: 618-549-5128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036122038
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: