=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952331993
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PASUPATHY PADMANABHAN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/04/2006
-----------------------------------------------------
Last Update Date | 03/13/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3375 N SEMINARY STREET
-----------------------------------------------------
City | GALESBURG
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-343-7775
-----------------------------------------------------
Fax | 309-343-2726
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 9382
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61612-9382
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-691-4410
-----------------------------------------------------
Fax | 309-589-2830
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 036051742
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------