MEDICARE: KETAN C. VYAS, M.D., LLC

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	207R00000X	Internal Medicine Physician	036091476	IL

General Provider Information

NPI Number	:	1700920097
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KETAN C. VYAS, M.D., LLC

Provider Business Mailing Address
First Line	:	610 N COURT ST
Second Line	:
City	:	GRAYVILLE
State	:	IL
Zip	:	62844-1002
Country	:	US
Telephone Number	:	618-375-7101
Fax Number	:	618-375-7183

Provider Business Practice Location Address
First Line	:	610 N COURT ST
Second Line	:
City	:	GRAYVILLE
State	:	IL
Zip	:	62844-1002
Country	:	US
Telephone Number	:	618-375-7101
Fax Number	:	618-375-7183

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KETAN C VYAS
Credential	:	M.D.
Telephone Number	:	618-375-7101

Provider Enumeration Date	:	02/19/2007
Last Update Date	:	07/15/2008

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