Healthcare Provider Details

I. General information

NPI: 1356327373
Provider Name (Legal Business Name): SESHADRICHARY NANDKUMAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 11/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1270 MERCANTILE DR
HIGHLAND IL
62249-1256
US

IV. Provider business mailing address

1280 MERCANTILE DR
HIGHLAND IL
62249-1256
US

V. Phone/Fax

Practice location:
  • Phone: 618-651-8097
  • Fax: 618-651-8097
Mailing address:
  • Phone: 618-654-8985
  • Fax: 618-654-8650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number036054213
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: