Healthcare Provider Details

I. General information

NPI: 1215552880
Provider Name (Legal Business Name): BABU PRASAD, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2035 W ILES AVE STE A
SPRINGFIELD IL
62704-7000
US

IV. Provider business mailing address

2035 W ILES AVE STE A
SPRINGFIELD IL
62704-7000
US

V. Phone/Fax

Practice location:
  • Phone: 217-787-9100
  • Fax: 217-787-6616
Mailing address:
  • Phone: 217-787-9100
  • Fax: 217-787-6616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: BABU PRASAD
Title or Position: OWNER
Credential: MD
Phone: 217-787-9100