Provider Demographics
NPI:1003836727
Name:VADALI, MAHESH (MD)
Entity Type:Individual
Prefix:
First Name:MAHESH
Middle Name:
Last Name:VADALI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 388320
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-8320
Mailing Address - Country:US
Mailing Address - Phone:773-767-4600
Mailing Address - Fax:773-767-8320
Practice Address - Street 1:10458 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-4933
Practice Address - Country:US
Practice Address - Phone:708-636-1818
Practice Address - Fax:708-636-2151
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2021-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086617207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0031601474OtherBLUE SHIELD
110152131OtherRAILROAD MEDICARE
IL036086617Medicaid
IL211194Medicare ID - Type Unspecified
IL036086617Medicaid