MEDICARE: DR. MAITRAYEE SUNDARESAN VADALI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician	036102767	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	P00157926	OTHER	IL	PALMETTO GBA INDIVIDUAL #
3	21622931	OTHER	ID	BCBS GROUP #
4	CI8250	OTHER	IL	PALMETTO GBA GROUP #

General Provider Information

NPI Number	:	1013900851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MAITRAYEE SUNDARESAN VADALI MD

Provider Business Mailing Address
First Line	:	12251 S 80TH AVE STE 1520
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1290
Country	:	US
Telephone Number	:	708-923-4200
Fax Number	:	708-923-4201

Provider Business Practice Location Address
First Line	:	12251 S 80TH AVE STE 1520
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1290
Country	:	US
Telephone Number	:	708-923-4200
Fax Number	:	708-923-4201

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2005
Last Update Date	:	11/30/2023

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