Healthcare Provider Details

I. General information

NPI: 1194064279
Provider Name (Legal Business Name): SWETHA VENNAVARAM M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2013
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

OSF SAINT FRANCIS MEDICAL CTR 530 NE GLEN OAK AVENUE
PEORIA IL
61637-0001
US

IV. Provider business mailing address

9711 N MEGAN CT
PEORIA IL
61615-7475
US

V. Phone/Fax

Practice location:
  • Phone: 309-624-9361
  • Fax:
Mailing address:
  • Phone: 309-573-5035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125062491
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036141852
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: