=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932691318
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAGADEESH BATANA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2018
-----------------------------------------------------
Last Update Date | 09/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2300 N EDWARD ST
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-475-1741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2300 N EDWARD ST
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62526-4192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-475-1741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RA0000X
-----------------------------------------------------
Taxonomy Name | Adolescent Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 036156035
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 036156035
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------