Healthcare Provider Details

I. General information

NPI: 1275799850
Provider Name (Legal Business Name): VENKATESH ANJAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

THREE SAINT ELIZABETH BLVD STE 2800
O FALLON IL
62269-1282
US

IV. Provider business mailing address

THREE SAINT ELIZABETH BLVD STE 2800
O FALLON IL
62269-1282
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-6044
  • Fax: 618-233-5195
Mailing address:
  • Phone: 618-233-6044
  • Fax: 618-233-5195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMT202334
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036127142
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036.127142
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: