Healthcare Provider Details

I. General information

NPI: 1801184767
Provider Name (Legal Business Name): SURYA TEJA CHATURVEDULA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2011
Last Update Date: 01/21/2020
Certification Date: 01/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5409 N KNOXVILLE AVE STE 207
PEORIA IL
61614-5069
US

IV. Provider business mailing address

5409 N KNOXVILLE AVE STE 207
PEORIA IL
61614-5069
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-4670
  • Fax: 309-672-4669
Mailing address:
  • Phone: 309-672-4670
  • Fax: 309-672-4669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036.147477
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: