Provider Demographics
NPI:1023222502
Name:GORANTLA GOVINDAIAH, M.D., S.C.
Entity Type:Organization
Organization Name:GORANTLA GOVINDAIAH, M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GORANTLA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOVINDAIAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-796-1510
Mailing Address - Street 1:4366 KENNEDY DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-4288
Mailing Address - Country:US
Mailing Address - Phone:309-796-1510
Mailing Address - Fax:309-796-1565
Practice Address - Street 1:4366 KENNEDY DR
Practice Address - Street 2:SUITE B
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-4288
Practice Address - Country:US
Practice Address - Phone:309-796-1510
Practice Address - Fax:309-796-1565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL263500OtherMEDICARE GROUP
IL8100279OtherBCBS
IL036049003Medicaid
ILK44585OtherMEDICARE INDIVIDUAL
010063712OtherRR MEDICARE
IA98669OtherWELLMARK BCBS
IA98669OtherWELLMARK BCBS