Healthcare Provider Details

I. General information

NPI: 1609435395
Provider Name (Legal Business Name): NOUPAMA NETHMINI MIRIHAGALLE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 19678
SPRINGFIELD IL
62794-9678
US

IV. Provider business mailing address

PO BOX 19678
SPRINGFIELD IL
62794-9678
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax:
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-1141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number036160072
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: