Healthcare Provider Details

I. General information

NPI: 1699763433
Provider Name (Legal Business Name): RAMAKRISHNA MADALA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 EAST CARPENTER ST ROOM 2K64
SPRINGFIELD IL
62769-0001
US

IV. Provider business mailing address

800 EAST CARPENTER ST ROOM 2K64
SPRINGFIELD IL
62769-0001
US

V. Phone/Fax

Practice location:
  • Phone: 217-525-5643
  • Fax: 217-544-2521
Mailing address:
  • Phone: 217-525-5643
  • Fax: 217-544-2521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: