Healthcare Provider Details

I. General information

NPI: 1699867275
Provider Name (Legal Business Name): RAMESH VAZZALWAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 DEMPSTER ST
PARK RIDGE IL
60068-1143
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 847-723-5313
  • Fax: 847-723-2338
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number036105371
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: