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General NPI Number Information
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NPI Number | 1215194519
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Entity Type | Organization
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Legal Business Name | MATHERS CLINIC, LLC
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Dates
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Enumeration Date | 05/22/2008
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Last Update Date | 05/22/2008
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Provider Practice Location Address
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Address Line | 5804 ELAINE DR
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City | ROCKFORD
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State | IL
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Zip | 61108-2435
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Country | US
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Telephone | 815-397-7654
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Fax | 815-397-2712
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Provider Business Mailing Address
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Address Line | 8420 W BRYN MAWR AVE SUITE 620
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City | CHICAGO
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State | IL
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Zip | 60631-3479
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Country | US
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Telephone | 773-775-2800
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Fax | 773-775-3366
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | DR. RAMESH BABU VEMURI
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Credential | MD
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Telephone | 815-397-7654
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number | 36039266
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License Number State | IL
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