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General NPI Number Information
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NPI Number | 1023222502
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Entity Type | Organization
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Legal Business Name | GORANTLA GOVINDAIAH, M.D., S.C.
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Dates
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Enumeration Date | 05/10/2007
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Last Update Date | 05/15/2008
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Provider Practice Location Address
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Address Line | 4366 KENNEDY DR SUITE B
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City | EAST MOLINE
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State | IL
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Zip | 61244-4288
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Country | US
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Telephone | 309-796-1510
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Fax | 309-796-1565
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Provider Business Mailing Address
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Address Line | 4366 KENNEDY DR SUITE B
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City | EAST MOLINE
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State | IL
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Zip | 61244-4288
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Country | US
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Telephone | 309-796-1510
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Fax | 309-796-1565
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Authorized Official
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Title or Position | OWNER
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Name | DR. GORANTLA GOVINDAIAH
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Credential | MD
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Telephone | 309-796-1510
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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