Healthcare Provider Details

I. General information

NPI: 1396169280
Provider Name (Legal Business Name): INTEGRAMED MEDICAL ILLINOIS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2014
Last Update Date: 02/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 N KNOXVILLE AVE SUITE 102
PEORIA IL
61614-5098
US

IV. Provider business mailing address

5401 N KNOXVILLE AVE SUITE 102
PEORIA IL
61614-5098
US

V. Phone/Fax

Practice location:
  • Phone: 309-689-0411
  • Fax:
Mailing address:
  • Phone: 309-689-0411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. SATISH VAYUVEGULA
Title or Position: PRESIDEN AND SECRETARY
Credential: M.D.
Phone: 309-689-0411